Healthcare Provider Details

I. General information

NPI: 1821054560
Provider Name (Legal Business Name): SHELLY HOLDER THOMPSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 KING ST
JACKSONVILLE FL
32204-2410
US

IV. Provider business mailing address

120 KING STREET
JACKSONVILLE FL
32204-2410
US

V. Phone/Fax

Practice location:
  • Phone: 904-760-4904
  • Fax: 904-760-4250
Mailing address:
  • Phone: 904-760-4904
  • Fax: 904-760-4250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0038917
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME38917
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: