Provider Demographics
NPI:1134853948
Name:SHINEGO, SUSAN (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SHINEGO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3085 SUNSET LANDING DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-4445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 BREEZEWAY ST STE 100
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3651
Practice Address - Country:US
Practice Address - Phone:904-427-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT13528208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation