Provider Demographics
NPI:1689004905
Name:BARTRA, SHANTELLE
Entity Type:Individual
Prefix:
First Name:SHANTELLE
Middle Name:
Last Name:BARTRA
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-7490
Mailing Address - Fax:239-343-4197
Practice Address - Street 1:16281 BASS RD STE 304
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-9687
Practice Address - Country:US
Practice Address - Phone:239-343-7490
Practice Address - Fax:239-343-4197
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9330396363L00000X
CA95010423363LP0200X
FLAPRN9330396363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115124300Medicaid
FL010291400Medicaid