Basic Information
| Provider Information | |||||||||
| NPI: | 1720731813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHURCHILL | ||||||||
| FirstName: | SHELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14690 SPRING HILL DR STE 305 | ||||||||
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| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346098102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522775348 | ||||||||
| FaxNumber: | 3526062857 | ||||||||
| Practice Location | |||||||||
| Address1: | 13235 STATE ROAD 52 STE 102 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346692968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273788503 | ||||||||
| FaxNumber: | 7278577807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2022 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | APRN11017691 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.