Provider Demographics
NPI:1699062661
Name:SEVERNS, SHELLY ANN (DC)
Entity type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:ANN
Last Name:SEVERNS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 W HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1941
Mailing Address - Country:US
Mailing Address - Phone:618-624-3600
Mailing Address - Fax:
Practice Address - Street 1:635 W HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1941
Practice Address - Country:US
Practice Address - Phone:618-624-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011937111N00000X
SC3641111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor