Provider Demographics
NPI:1912402934
Name:NALL, SHANE WILDING (LMT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:WILDING
Last Name:NALL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14985 OLD SAINT AUGUSTINE RD UNIT 106
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-9478
Mailing Address - Country:US
Mailing Address - Phone:904-288-9491
Mailing Address - Fax:904-288-9698
Practice Address - Street 1:14985 OLD SAINT AUGUSTINE RD UNIT 106
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-9478
Practice Address - Country:US
Practice Address - Phone:904-288-9491
Practice Address - Fax:904-288-9698
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA88028225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist