Healthcare Provider Details

I. General information

NPI: 1134853948
Provider Name (Legal Business Name): SUSAN SHINEGO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2022
Last Update Date: 07/16/2022
Certification Date: 07/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 BREEZEWAY ST STE 100
YULEE FL
32097-3651
US

IV. Provider business mailing address

3085 SUNSET LANDING DR
JACKSONVILLE FL
32226-4445
US

V. Phone/Fax

Practice location:
  • Phone: 904-427-8300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT13528
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: