=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740677210
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNETTE M AILES NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2015
-----------------------------------------------------
Last Update Date | 05/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 N 12TH AVE BLDG B
-----------------------------------------------------
City | ARCADIA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34266-8752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-494-1242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 8TH AVE W STE 101
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-4737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-776-4000
-----------------------------------------------------
Fax | 941-845-4963
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 71005432A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71005432A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN11012677
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------