Provider Demographics
NPI:1154492262
Name:SHORES, NANCY C (LMT)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:C
Last Name:SHORES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 PHILIPS MANOR RD
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-5341
Mailing Address - Country:US
Mailing Address - Phone:904-415-5589
Mailing Address - Fax:904-261-8875
Practice Address - Street 1:1894 S 14TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4494
Practice Address - Country:US
Practice Address - Phone:904-261-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA00030617225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2292Medicare UPIN