Basic Information
| Provider Information | |||||||||
| NPI: | 1407088727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELLEM | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816573 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MEDICAL PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434815300 | ||||||||
| FaxNumber: | 4434816705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2009 | ||||||||
| LastUpdateDate: | 12/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | R153442 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 025825300 | 05 | MD | MEDICAID | V8740009 | 01 | DC | BCBS | OTHER | 169723ZCU2 | 01 | MD | MEDICARE GROUP MEMBER PTAN | OTHER | 95586303 | 01 | MD | BCBS MD | OTHER | V8380009 | 01 | DC | BCBS | OTHER | 95586304 | 01 | MD | BCBS | OTHER | 95586305 | 01 | MD | BCBS | OTHER | V8080009 | 01 | DC | BCBS | OTHER | 9284514 | 01 | MD | AETNA PPO | OTHER | 11995694 | 01 | MD | COUNCIL FOR AFFORDABLE QUALITY HEALTHCARE | OTHER | 8057972 | 01 | MD | AETNA HMO | OTHER |