Provider Demographics
NPI:1558329300
Name:JAQUISH, SHELLEY SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:SUE
Last Name:JAQUISH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10002 PRINCESS PALM AVE STE 332
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-8327
Mailing Address - Country:US
Mailing Address - Phone:813-571-7184
Mailing Address - Fax:813-654-4695
Practice Address - Street 1:6827 FIRST AVENUE SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-4516
Practice Address - Country:US
Practice Address - Phone:727-341-0551
Practice Address - Fax:727-341-0332
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82762207YX0602X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280250OtherAVMED
FL2597386OtherAETNA
FL1000331OtherUNITED HEALTH CARE
FL220342OtherAMERIGROUP
FL01150OtherBCBS
FL261879600Medicaid
FL3839012002OtherCIGNA
FL2597386OtherAETNA
FL3839012002OtherCIGNA