Provider Demographics
NPI:1578030334
Name:WAALKES, SHELBY IRENE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:IRENE
Last Name:WAALKES
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:IRENE
Other - Last Name:DEWITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP-BC
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3640
Mailing Address - Fax:239-343-3452
Practice Address - Street 1:13681 DOCTORS WAY STE 18026
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4300
Practice Address - Country:US
Practice Address - Phone:239-343-3640
Practice Address - Fax:239-343-3452
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704249824363LA2100X
FLAPRN11031162363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL126596200Medicaid