Provider Demographics
NPI:1043967722
Name:SHELLENBARGER, TANNER
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:SHELLENBARGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11850 DR MARTIN LUTHER KING JR ST N APT 3307
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4655 66TH ST N STE 22B
Practice Address - Street 2:
Practice Address - City:KENNETH CITY
Practice Address - State:FL
Practice Address - Zip Code:33709-4827
Practice Address - Country:US
Practice Address - Phone:727-546-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist