Provider Demographics
NPI:1871632455
Name:SHELTON, JILL SUZANNE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:SUZANNE
Last Name:SHELTON
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 1:1315 N TUSTIN ST # I-383
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-3905
Mailing Address - Country:US
Mailing Address - Phone:714-547-3346
Mailing Address - Fax:714-547-3252
Practice Address - Street 1:1315 N TUSTIN ST # I-383
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-3905
Practice Address - Country:US
Practice Address - Phone:714-547-3346
Practice Address - Fax:714-547-3252
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP10567363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP07443Medicare UPIN
CANP10567Medicare ID - Type Unspecified