Provider Demographics
NPI:1528580891
Name:VANN, SHELLY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:VANN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7399 LONGLEAF PINE PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-6970
Mailing Address - Country:US
Mailing Address - Phone:904-547-8340
Mailing Address - Fax:
Practice Address - Street 1:7399 LONGLEAF PINE PKWY
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-6970
Practice Address - Country:US
Practice Address - Phone:904-547-8340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL16162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer