Provider Demographics
NPI:1235957853
Name:SHELTON, SHANE LAROY (PMHNP)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:LAROY
Last Name:SHELTON
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4108
Mailing Address - Country:US
Mailing Address - Phone:541-409-4066
Mailing Address - Fax:
Practice Address - Street 1:880 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4108
Practice Address - Country:US
Practice Address - Phone:541-409-4066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10028471363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health