Healthcare Provider Details

I. General information

NPI: 1023064292
Provider Name (Legal Business Name): SHELLEY SMITH TICKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLEY SMITH STEVENS

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E BLOOMINGDALE AVE STE 501
BRANDON FL
33511-8118
US

IV. Provider business mailing address

14902 HERONGLEN DR
LITHIA FL
33547-5887
US

V. Phone/Fax

Practice location:
  • Phone: 813-699-3995
  • Fax:
Mailing address:
  • Phone: 813-317-1591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME90313
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: