MEDICARE: SHELLY LYNN WILEY PTA

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	225200000X	Physical Therapy Assistant	PTA15046	FL

General Provider Information

NPI Number	:	1881839777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLY LYNN WILEY PTA

Provider Business Mailing Address
First Line	:	10250 NORMANDY BLVD
Second Line	:	STE 502
City	:	JACKSONVILLE
State	:	FL
Zip	:	32221-8059
Country	:	US
Telephone Number	:	904-693-4516
Fax Number	:	804-693-4518

Provider Business Practice Location Address
First Line	:	10250 NORMANDY BLVD
Second Line	:	STE502
City	:	JACKSONVILLE
State	:	FL
Zip	:	32221-8059
Country	:	US
Telephone Number	:	904-693-4516
Fax Number	:	904-693-4518

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

Provider Enumeration Date	:	12/08/2008
Last Update Date	:	05/28/2015

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