Basic Information
| Provider Information | |||||||||
| NPI: | 1861858599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUESDELL | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ALLISON | ||||||||
| OtherFirstName: | SHELLY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | VANCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411790550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067963029 | ||||||||
| FaxNumber: | 6067966221 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 ELIZAVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | FLEMINGSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410411141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068450028 | ||||||||
| FaxNumber: | 6068450263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2016 | ||||||||
| LastUpdateDate: | 01/21/2019 | ||||||||
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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 | 363LF0000X | 3010028 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100392470 | 05 | KY | MEDICAID |