Provider Demographics
NPI:1700207966
Name:SHIRLEY, KALEENA (PA-C)
Entity Type:Individual
Prefix:
First Name:KALEENA
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15255 MAX LEGGETT PKWY
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7273
Mailing Address - Country:US
Mailing Address - Phone:904-427-7777
Mailing Address - Fax:
Practice Address - Street 1:15255 MAX LEGGETT PKWY
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7273
Practice Address - Country:US
Practice Address - Phone:904-427-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2016-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003175081AMedicaid
FL016381600Medicaid
FLP01637406Medicare PIN
FLIK528ZMedicare PIN