Provider Demographics
NPI:1366812513
Name:SHELY, DEANNE KRISTEN (FNP)
Entity type:Individual
Prefix:
First Name:DEANNE
Middle Name:KRISTEN
Last Name:SHELY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14144 PORTRUSH DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8244
Mailing Address - Country:US
Mailing Address - Phone:407-491-5600
Mailing Address - Fax:
Practice Address - Street 1:130 E MARKS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3817
Practice Address - Country:US
Practice Address - Phone:407-505-6435
Practice Address - Fax:386-206-5020
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001792363LF0000X
FLAPRN11000645363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104421000Medicaid