Provider Demographics
NPI:1598439325
Name:LENK, SHELBY LATRELLE
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LATRELLE
Last Name:LENK
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 1:122 LITTLE TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32327-1302
Mailing Address - Country:US
Mailing Address - Phone:850-242-1735
Mailing Address - Fax:
Practice Address - Street 1:2930 CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4408
Practice Address - Country:US
Practice Address - Phone:850-242-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program