Basic Information
| Provider Information | |||||||||
| NPI: | 1740910512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SHELBY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1416 N M L KING JR BLVD UNIT 1 | ||||||||
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| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323035490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785518392 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 MICCOSUKEE RD | ||||||||
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| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504311155 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2022 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 770 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.