Provider Demographics
NPI:1407349384
Name:FASANELLA, SHAYNA
Entity Type:Individual
Prefix:MS
First Name:SHAYNA
Middle Name:
Last Name:FASANELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAYNA
Other - Middle Name:
Other - Last Name:FASANELLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:5540 PGA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3987
Mailing Address - Country:US
Mailing Address - Phone:561-571-4000
Mailing Address - Fax:561-491-2271
Practice Address - Street 1:5540 PGA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-3987
Practice Address - Country:US
Practice Address - Phone:561-571-4000
Practice Address - Fax:561-491-2271
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008742363AM0700X
FLPA9112616363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical