Provider Demographics
NPI:1770978074
Name:SEDBERRY, SHELLY DIANE (DPM)
Entity type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:DIANE
Last Name:SEDBERRY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4427
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-4427
Mailing Address - Country:US
Mailing Address - Phone:417-622-0648
Mailing Address - Fax:417-622-0497
Practice Address - Street 1:1801 W 32ND ST BLDG C
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:405-819-8013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12-00438213ES0103X
MO2018010120213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery