=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942020185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHINEY ALEX JACOB PHD, DNP, MSHI, MPH,
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2024
-----------------------------------------------------
Last Update Date | 10/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 366 BRENTWOOD CLUB CV
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32750-3352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-527-9025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 366 BRENTWOOD CLUB CV
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32750-3352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-527-9025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11031671
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------