Provider Demographics
NPI:1053412742
Name:SHY, MARY E (FNP-CS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:SHY
Suffix:
Gender:F
Credentials:FNP-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:WALSH
Mailing Address - State:CO
Mailing Address - Zip Code:81090-0608
Mailing Address - Country:US
Mailing Address - Phone:719-543-6633
Mailing Address - Fax:719-543-6655
Practice Address - Street 1:PO BOX 608
Practice Address - Street 2:
Practice Address - City:WALSH
Practice Address - State:CO
Practice Address - Zip Code:81090-0608
Practice Address - Country:US
Practice Address - Phone:719-543-6633
Practice Address - Fax:719-543-6655
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
45253OtherKANSAS BOARD OF HEALING ARTS
CO58851747Medicaid
CO58851747Medicaid