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General NPI Number Information
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NPI Number | 1356088264
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Entity Type | Individual
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Provider Name | KELLY SHUTTERA
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Gender | Female
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Dates
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Enumeration Date | 05/13/2022
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Last Update Date | 05/13/2022
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Provider Practice Location Address
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Address Line | 100 N MAIN ST
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City | CHATTAHOOCHEE
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State | FL
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Zip | 32324-1107
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Country | US
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Telephone | 850-663-7001
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Fax |
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Provider Business Mailing Address
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Address Line | 1724 GURTLER CT APT 2
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City | ORLANDO
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State | FL
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Zip | 32804-6428
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Country | US
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Telephone | 310-499-8697
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 110119463
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License Number State | FL
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