Healthcare Provider Details

I. General information

NPI: 1871744730
Provider Name (Legal Business Name): SHANE CATHERINE WARD A.R.N.P., CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 09/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5992 BERRYHILL RD SUITE 201
MILTON FL
32570-1013
US

IV. Provider business mailing address

3932 OTTER POND RD
WESTVILLE FL
32464-2809
US

V. Phone/Fax

Practice location:
  • Phone: 850-626-9626
  • Fax: 850-626-9606
Mailing address:
  • Phone: 850-859-2611
  • Fax: 850-859-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9181246
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-119971
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: