Provider Demographics
NPI:1255958518
Name:SHIELDS, MARIE CAROL (NURSE PRACTITIONER,)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:CAROL
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER,
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:SHIELDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:5036 SW 87TH TER
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33328-4334
Mailing Address - Country:US
Mailing Address - Phone:195-439-4975
Mailing Address - Fax:
Practice Address - Street 1:5036 SW 87TH TER
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33328-4334
Practice Address - Country:US
Practice Address - Phone:954-394-9758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL110011858363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11011858OtherFLORIDA DEPARTMENT OF HEALTH
FLRN--9233024OtherREGISTERED NURSE