Provider Demographics
NPI:1679927123
Name:SHELBURNE, SHANLEY BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:SHANLEY
Middle Name:BROOKE
Last Name:SHELBURNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANLEY
Other - Middle Name:BROOKE
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:41830 E MORGAN AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24277-3218
Mailing Address - Country:US
Mailing Address - Phone:336-512-3162
Mailing Address - Fax:
Practice Address - Street 1:1800 COMBS RD
Practice Address - Street 2:SUITE 7
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-1808
Practice Address - Country:US
Practice Address - Phone:276-546-4894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005327363AM0700X
KYTC481363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical