Provider Demographics
NPI:1447894167
Name:GERTEISEN, SHELLY CHRISTIAN (APRN)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:CHRISTIAN
Last Name:GERTEISEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:POTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9510 ORMSBY STATION RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5016
Mailing Address - Country:US
Mailing Address - Phone:502-327-9100
Mailing Address - Fax:855-632-8329
Practice Address - Street 1:8070 US HIGHWAY 60 W
Practice Address - Street 2:
Practice Address - City:LEWISPORT
Practice Address - State:KY
Practice Address - Zip Code:42351-7087
Practice Address - Country:US
Practice Address - Phone:270-295-3777
Practice Address - Fax:855-625-0821
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009653A363LF0000X
KY3013546363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100640130Medicaid
14573272OtherCAQH