Basic Information
| Provider Information | |||||||||
| NPI: | 1740677210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AILES | ||||||||
| FirstName: | SHANNETTE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 8TH AVE W STE 101 | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342214737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417764000 | ||||||||
| FaxNumber: | 9418454963 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 N 12TH AVE BLDG B | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342668752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634941242 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2015 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71005432A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 71005432A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | APRN11012677 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 201286480 | 05 | IN | MEDICAID | 000000938346 | 01 | IN | ANTHEM (REID PHYSICIAN ASSOCIATES, INC.) | OTHER | 0128143 | 05 | OH | MEDICAID |