1336371640 NPI number — ELIZEBETH J SHALALA LMT

Table of content: ELIZEBETH J SHALALA LMT (NPI 1336371640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336371640 NPI number — ELIZEBETH J SHALALA LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHALALA
Provider First Name:
ELIZEBETH
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSS
Provider Other First Name:
ELIZEBETH
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1336371640
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
969 COUNTRY CLUB DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TITUSVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32780-4985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-225-9788
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 MAIN ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TITUSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32796-3590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-225-9788
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 246RP1900X , with the licence number:  3019910435 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246Z00000X , with the licence number: 3019910444 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246Z00000X , with the licence number: 3019910440 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: MA103702 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)