Provider Demographics
NPI:1356088264
Name:SHUTTERA, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHUTTERA
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 1:1724 GURTLER CT APT 2
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6428
Mailing Address - Country:US
Mailing Address - Phone:310-499-8697
Mailing Address - Fax:
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-1107
Practice Address - Country:US
Practice Address - Phone:850-663-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL110119463363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health