Basic Information
| Provider Information | |||||||||
| NPI: | 1780983759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELTON | ||||||||
| FirstName: | NIKKI | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997094220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516390 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3830 S CUSHMAN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074551407 | ||||||||
| FaxNumber: | 9074551460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 03/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.