Healthcare Provider Details

I. General information

NPI: 1174543565
Provider Name (Legal Business Name): SHEA ANN HUMPHREY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1296 W BROAD ST
GROVELAND FL
34736-2012
US

IV. Provider business mailing address

110 S WOODLAND ST
WINTER GARDEN FL
34787-3546
US

V. Phone/Fax

Practice location:
  • Phone: 352-429-4104
  • Fax: 352-429-4138
Mailing address:
  • Phone: 407-905-8827
  • Fax: 407-905-8980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS9643
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: