MEDICARE: MARY GRANTHAM SHELTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1427991173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY GRANTHAM SHELTON

Provider Business Mailing Address
First Line	:	3701 PINE TIP RD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32312-1016
Country	:	US
Telephone Number	:	850-694-0492
Fax Number	:

Provider Business Practice Location Address
First Line	:	3701 PINE TIP RD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32312-1016
Country	:	US
Telephone Number	:	850-694-0492
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2026
Last Update Date	:	04/09/2026

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