Provider Demographics
NPI:1265860688
Name:YOUNG, SHIRLEY FAYE
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:FAYE
Last Name:YOUNG
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 1:639 E JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-3902
Mailing Address - Country:US
Mailing Address - Phone:850-417-5834
Mailing Address - Fax:
Practice Address - Street 1:639 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-3902
Practice Address - Country:US
Practice Address - Phone:850-417-5834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL233301251G00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008309400Medicaid