Provider Demographics
NPI:1053568048
Name:SHELLENBARGER, KAREN COURTNEY (NP)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:COURTNEY
Last Name:SHELLENBARGER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:COURTNEY
Other - Last Name:THORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655
Practice Address - Country:US
Practice Address - Phone:774-441-7615
Practice Address - Fax:508-856-4287
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2324819363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2926614Medicaid