Basic Information
| Provider Information | |||||||||
| NPI: | 1083108500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAULSON | ||||||||
| FirstName: | SHENELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 BELFORT RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043987205 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3 SHIRCLIFF WAY STE 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043819393 | ||||||||
| FaxNumber: | 9043819314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2018 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9330550 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 100875000 | 05 | FL | MEDICAID | KM318 | 01 | FL | MEDICARE PIN | OTHER |