Provider Demographics
NPI:1255562815
Name:LENGEFELD, SHELLY S (PA)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:S
Last Name:LENGEFELD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 N BROWN ST
Mailing Address - Street 2:BLDG. I
Mailing Address - City:HAMILTON
Mailing Address - State:TX
Mailing Address - Zip Code:76531-1518
Mailing Address - Country:US
Mailing Address - Phone:254-386-1700
Mailing Address - Fax:257-386-4839
Practice Address - Street 1:400 N BROWN ST
Practice Address - Street 2:BLDG. II
Practice Address - City:HAMILTON
Practice Address - State:TX
Practice Address - Zip Code:76531-1518
Practice Address - Country:US
Practice Address - Phone:254-386-1700
Practice Address - Fax:254-386-4839
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA04852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant