Provider Demographics
NPI:1497439772
Name:SHELLEH, AMMAL (PA)
Entity type:Individual
Prefix:
First Name:AMMAL
Middle Name:
Last Name:SHELLEH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3400
Mailing Address - Country:US
Mailing Address - Phone:321-843-6812
Mailing Address - Fax:321-843-6812
Practice Address - Street 1:10000 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3400
Practice Address - Country:US
Practice Address - Phone:321-843-6812
Practice Address - Fax:321-843-6812
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9118055363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120832300Medicaid
FLSB409OtherMEDICARE HFPSI
FLSB410OtherMEDICARE HFMG