Provider Demographics
NPI:1558125476
Name:SHIELDS, JEANNIE VILLANUEVA
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:VILLANUEVA
Last Name:SHIELDS
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 1:3717 BERRY PATCH LN
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-6327
Mailing Address - Country:US
Mailing Address - Phone:850-292-7961
Mailing Address - Fax:
Practice Address - Street 1:4624 SUMMERDALE BLVD
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1368
Practice Address - Country:US
Practice Address - Phone:850-944-3456
Practice Address - Fax:850-994-3476
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16654235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist