Provider Demographics
NPI:1346483856
Name:SHIRLEY, SUSAN GRAY (ARNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GRAY
Last Name:SHIRLEY
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 1:4337 KEYSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-1601
Mailing Address - Country:US
Mailing Address - Phone:813-737-1953
Mailing Address - Fax:
Practice Address - Street 1:4651 CHARLOTTE PARK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1956
Practice Address - Country:US
Practice Address - Phone:813-977-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2733542363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002221700Medicaid
FL002221700Medicaid