MEDICARE: MRS. REBECCA L SHELLEY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	RN 9173615	FL

General Provider Information

NPI Number	:	1487653150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA L SHELLEY RN

Provider Business Mailing Address
First Line	:	7 OLD CREEK CIR
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-2699
Country	:	US
Telephone Number	:	386-672-7869
Fax Number	:	386-672-7869

Provider Business Practice Location Address
First Line	:	408 S RIDGEWOOD AVE
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-4928
Country	:	US
Telephone Number	:	386-236-3261
Fax Number	:	386-236-3135

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	07/08/2007

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