Healthcare Provider Details

I. General information

NPI: 1952575854
Provider Name (Legal Business Name): SHAWYNTEE MIREILLE MAYO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAWYNTEE MIREILLE VERTILUS M.D.

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR STE 280
JACKSONVILLE FL
32207-8350
US

IV. Provider business mailing address

PO BOX 746645
ATLANTA GA
30374-6645
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-8550
  • Fax: 904-393-7808
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME131416
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number208000000X
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberP1706
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME131416
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: