Basic Information
Provider Information | |||||||||
NPI: | 1750854311 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KING | ||||||||
FirstName: | SHELITA | ||||||||
MiddleName: | SPEARS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4700 MILLENIA LAKES BLVD | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328397823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075336837 | ||||||||
FaxNumber: | 4077700661 | ||||||||
Practice Location | |||||||||
Address1: | 2314 S RANGE AVE | ||||||||
Address2: |   | ||||||||
City: | DENHAM SPRINGS | ||||||||
State: | LA | ||||||||
PostalCode: | 707265216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2254804080 | ||||||||
FaxNumber: | 8774854275 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/07/2019 | ||||||||
LastUpdateDate: | 05/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 200698 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.