Provider Demographics
NPI:1699915165
Name:VANACKEREN, SHELLEY LYNN
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:LYNN
Last Name:VANACKEREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 N 203RD ST STE 3
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-2889
Mailing Address - Country:US
Mailing Address - Phone:402-289-5013
Mailing Address - Fax:402-289-5018
Practice Address - Street 1:1908 N 203RD ST STE 3
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-2889
Practice Address - Country:US
Practice Address - Phone:402-289-5013
Practice Address - Fax:402-289-5018
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE296225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
216812OtherCOVENTRY
39960OtherBCBS
41213595668022A002OtherTRI WEST
099709OtherMEDICARE GROUP
NE10025112300Medicaid
099709OtherMEDICARE GROUP