Provider Demographics
NPI:1447546718
Name:SKJOLAAS-LINDELL, SHELLY LEE (OD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:LEE
Last Name:SKJOLAAS-LINDELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:LEE
Other - Last Name:SKJOLAA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2300 US HIGHWAY 51 AND 138
Mailing Address - Street 2:STE E
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-2080
Mailing Address - Country:US
Mailing Address - Phone:608-205-2293
Mailing Address - Fax:608-205-6813
Practice Address - Street 1:2300 US HIGHWAY 51 AND 138
Practice Address - Street 2:STE E
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-2080
Practice Address - Country:US
Practice Address - Phone:608-205-2293
Practice Address - Fax:608-205-6813
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007713152W00000X
WI3402-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03361759Medicaid
NY03361759Medicaid