=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023064292
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLEY SMITH TICKETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 07/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 E BLOOMINGDALE AVE STE 501
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-8118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-699-3995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14902 HERONGLEN DR
-----------------------------------------------------
City | LITHIA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33547-5887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-317-1591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME90313
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------