Provider Demographics
NPI:1083162457
Name:SHELTON, HEATHER LUTZ (ARNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LUTZ
Last Name:SHELTON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:PEDIATRIC DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8203
Mailing Address - Fax:850-863-8113
Practice Address - Street 1:1005 MAR WALT DRIVE
Practice Address - Street 2:PEDIATRIC DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6796
Practice Address - Country:US
Practice Address - Phone:850-863-8203
Practice Address - Fax:850-863-8113
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1951032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF0Y5WOtherBCBSFL
FL018830000Medicaid
FLF0Y5WOtherBCBSFL