Provider Demographics
NPI:1871021451
Name:SHOFFNER, MARY LYNNETTE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNNETTE
Last Name:SHOFFNER
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 1:2671 HUFFMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2671 HUFFMAN BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4056
Practice Address - Country:US
Practice Address - Phone:904-425-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1400225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist