Provider Demographics
NPI:1720855141
Name:DERMATOLOGY & SKIN CARE BY SHELLY
Entity type:Organization
Organization Name:DERMATOLOGY & SKIN CARE BY SHELLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, DCNP
Authorized Official - Phone:928-499-2915
Mailing Address - Street 1:PMB PO BOX 416
Mailing Address - Street 2:1042 WILLOW CREEK RD SUITE A101
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301
Mailing Address - Country:US
Mailing Address - Phone:928-899-4455
Mailing Address - Fax:
Practice Address - Street 1:1598 SUSAN A WILLIAMS WAY
Practice Address - Street 2:SUITE E
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-5957
Practice Address - Country:US
Practice Address - Phone:928-499-2915
Practice Address - Fax:877-406-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-06
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty