1053148676 NPI number — MS. SHANDEL NELSON CALLAWAY(MAIDEN)

Table of content: MS. SHANDEL NELSON CALLAWAY(MAIDEN) (NPI 1053148676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053148676 NPI number — MS. SHANDEL NELSON CALLAWAY(MAIDEN)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
SHANDEL
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CALLAWAY(MAIDEN)
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CALLAWAY -NELSON
Provider Other First Name:
SHANDEL
Provider Other Middle Name:
Provider Other Name Prefix Text:
PROF.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CALLAWAY(MAIDEN)
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1053148676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4455 CONFEDERATE POINT RD APT 8C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32210-5720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-635-4554
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8277 SAILMAKER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32210-3456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-635-4554
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2024

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: 376K00000X , with the licence number:  107772 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 376K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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