Provider Demographics
NPI:1184039695
Name:SHIPLEY, NATHAN E
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:E
Last Name:SHIPLEY
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 1:2338 ALTON RD.
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952
Mailing Address - Country:US
Mailing Address - Phone:941-268-9821
Mailing Address - Fax:
Practice Address - Street 1:2338 ALTON RD.
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952
Practice Address - Country:US
Practice Address - Phone:941-268-9821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172A00000X, 372600000X, 374U00000X, 376G00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No172A00000XOther Service ProvidersDriver
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
#553509OtherATN
FLATN#553509Medicaid