Provider Demographics
NPI:1871373167
Name:LUPIAN, SHELLY LYNN (LDO)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:LYNN
Last Name:LUPIAN
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 KAREN WAY
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6177
Mailing Address - Country:US
Mailing Address - Phone:909-362-9747
Mailing Address - Fax:
Practice Address - Street 1:2840 HWAY 95
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7792
Practice Address - Country:US
Practice Address - Phone:928-758-1450
Practice Address - Fax:928-758-1683
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ002528156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician