Provider Demographics
NPI:1689400392
Name:SUNDRE, SHELBY MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:MARIE
Last Name:SUNDRE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:MARIE
Other - Last Name:MARX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2786 FAIRVIEW AVE N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1306
Mailing Address - Country:US
Mailing Address - Phone:763-412-1993
Mailing Address - Fax:
Practice Address - Street 1:2786 FAIRVIEW AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1306
Practice Address - Country:US
Practice Address - Phone:763-412-1993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10114363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily