1740677210 NPI number — SHANNETTE M AILES NP-C

Table of content: SHANNETTE M AILES NP-C (NPI 1740677210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740677210 NPI number — SHANNETTE M AILES NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AILES
Provider First Name:
SHANNETTE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740677210
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 8TH AVE W STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALMETTO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34221-4737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-776-4000
Provider Business Mailing Address Fax Number:
941-845-4963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 N 12TH AVE BLDG B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCADIA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34266-8752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-494-1242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2015

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: 363L00000X , with the licence number:  71005432A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 71005432A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: APRN11012677 , 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)

  • Identifier: 201286480 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000938346 . This is a "ANTHEM (REID PHYSICIAN ASSOCIATES, INC.)" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 0128143 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110557200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com