Healthcare Provider Details

I. General information

NPI: 1821157504
Provider Name (Legal Business Name): CARMEN ANITA SHIRLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 FRONT ST FL 6
JUPITER FL
33477-5095
US

IV. Provider business mailing address

110 FRONT ST FL 6
JUPITER FL
33477-5095
US

V. Phone/Fax

Practice location:
  • Phone: 210-495-0224
  • Fax: 210-247-9326
Mailing address:
  • Phone: 210-495-0224
  • Fax: 210-247-9326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberME67429
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: