Provider Demographics
NPI:1548484587
Name:SHEA, KELLY MAUREEN (RCPH)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MAUREEN
Last Name:SHEA
Suffix:
Gender:F
Credentials:RCPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8636 WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4830
Mailing Address - Country:US
Mailing Address - Phone:904-739-0807
Mailing Address - Fax:904-367-0364
Practice Address - Street 1:8636 WINCHESTER DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4830
Practice Address - Country:US
Practice Address - Phone:904-739-0807
Practice Address - Fax:904-367-0364
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 22538183500000X
FL1835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835G0303XPharmacy Service ProvidersPharmacistGeriatric