Provider Demographics
NPI:1043912546
Name:FERNANDEZ, SHELLY
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11808 N OHIO ST
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34431-6724
Mailing Address - Country:US
Mailing Address - Phone:352-812-1849
Mailing Address - Fax:844-921-1442
Practice Address - Street 1:11808 N OHIO ST
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34431-6724
Practice Address - Country:US
Practice Address - Phone:352-812-1849
Practice Address - Fax:844-921-1442
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-263808106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician