Provider Demographics
NPI:1619707676
Name:LUMMUS, SHELLY MAE
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:MAE
Last Name:LUMMUS
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 1:207 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3626
Mailing Address - Country:US
Mailing Address - Phone:208-365-1065
Mailing Address - Fax:
Practice Address - Street 1:207 E 12TH ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3626
Practice Address - Country:US
Practice Address - Phone:208-365-1065
Practice Address - Fax:208-365-1065
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000111135172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker