Basic Information
| Provider Information | |||||||||
| NPI: | 1871568105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 5TH ST S | ||||||||
| Address2: | DEPT #6500002705 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277673051 | ||||||||
| FaxNumber: | 7277674970 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 6TH AVE S | ||||||||
| Address2: | DEPT #6580071309 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674147 | ||||||||
| FaxNumber: | 7277678408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 08/11/2016 | ||||||||
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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 | 363LP0200X | ARNP1402992 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 008583600 | 05 | FL | MEDICAID |