Individual
SHELLEY SMITH TICKETT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
901 E BLOOMINGDALE AVE STE 501, BRANDON, FL 33511-8118
(813) 699-3995
Mailing address
14902 HERONGLEN DR, LITHIA, FL 33547-5887
(813) 317-1591
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
ME90313
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
269812900
—
FL
01
—
44141
BCBS OF FLORIDA
FL
Enumeration date
05/26/2006
Last updated
07/01/2024
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