Provider Demographics
NPI:1598457103
Name:HEATLY, SHANTE (APRN)
Entity Type:Individual
Prefix:
First Name:SHANTE
Middle Name:
Last Name:HEATLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 28TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-1526
Mailing Address - Country:US
Mailing Address - Phone:727-687-5558
Mailing Address - Fax:
Practice Address - Street 1:1200 7TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1300
Practice Address - Country:US
Practice Address - Phone:727-825-1065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026421363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily