Provider Demographics
NPI:1144513904
Name:GATTIS, SHELBY MARIE (NNP)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:MARIE
Last Name:GATTIS
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16181 W YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-5746
Mailing Address - Country:US
Mailing Address - Phone:623-572-5482
Mailing Address - Fax:
Practice Address - Street 1:5555 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4622
Practice Address - Country:US
Practice Address - Phone:602-865-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4051363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ145854Medicare PIN