Healthcare Provider Details

I. General information

NPI: 1164081766
Provider Name (Legal Business Name): SHELBY LEEANN SHEIDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELBY LEEANN WENTWORTH MD

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 HILDEN RD STE 201
PONTE VEDRA FL
32081-8400
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-1941
  • Fax: 904-391-7460
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number86491
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME166306
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: