Healthcare Provider Details

I. General information

NPI: 1154878825
Provider Name (Legal Business Name): SHELBY MILLER JENKINS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 02/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N AVALON WAY
LECANTO FL
34461-6004
US

IV. Provider business mailing address

PO BOX 1990
CRYSTAL RIVER FL
34423-1990
US

V. Phone/Fax

Practice location:
  • Phone: 352-746-2663
  • Fax: 352-746-6907
Mailing address:
  • Phone: 352-746-4176
  • Fax: 352-746-6907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109716
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: