Provider Demographics
NPI:1871190157
Name:CLYBURN, SHENNA MICHELLE
Entity Type:Individual
Prefix:
First Name:SHENNA
Middle Name:MICHELLE
Last Name:CLYBURN
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 1:3112 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-3531
Mailing Address - Country:US
Mailing Address - Phone:772-666-0672
Mailing Address - Fax:
Practice Address - Street 1:3112 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-3531
Practice Address - Country:US
Practice Address - Phone:772-666-0672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care