Provider Demographics
NPI:1023064292
Name:TICKETT, SHELLEY SMITH
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:SMITH
Last Name:TICKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:SMITH
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14902 HERONGLEN DR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-5887
Mailing Address - Country:US
Mailing Address - Phone:813-317-1591
Mailing Address - Fax:
Practice Address - Street 1:901 E BLOOMINGDALE AVE STE 501
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8118
Practice Address - Country:US
Practice Address - Phone:813-699-3995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90313208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269812900Medicaid
FL44141OtherBCBS OF FLORIDA
FL269812900Medicaid
FL44141YMedicare PIN
FLP00278159Medicare PIN
FL44141OtherBCBS OF FLORIDA
FL44141XMedicare PIN