Basic Information
Provider Information | |||||||||
NPI: | 1346375219 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAYLOR | ||||||||
FirstName: | SHELLY | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2675 WINKLER AVE FL 2 | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339019342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778563774 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 21297 OLEAN BLVD STE A | ||||||||
Address2: |   | ||||||||
City: | PORT CHARLOTTE | ||||||||
State: | FL | ||||||||
PostalCode: | 339526704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8559795700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2007 | ||||||||
LastUpdateDate: | 07/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | ARNP 2879292 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LF0000X | 3015904 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | ARNP 2879292 | 01 | FL | STATE LICENSE | OTHER |