Provider Demographics
NPI:1598202541
Name:WILKIN, SHELLEY
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:
Last Name:WILKIN
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 1:6545 W. SR 44
Mailing Address - Street 2:
Mailing Address - City:LAKE PANASOFFKEE
Mailing Address - State:FL
Mailing Address - Zip Code:33538-3123
Mailing Address - Country:US
Mailing Address - Phone:740-457-6055
Mailing Address - Fax:
Practice Address - Street 1:6545 W. SR 44
Practice Address - Street 2:
Practice Address - City:LAKE PANASOFFKEE
Practice Address - State:FL
Practice Address - Zip Code:33538-3123
Practice Address - Country:US
Practice Address - Phone:740-457-6055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 15176224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant