Provider Demographics
NPI:1568935336
Name:SHAH, SERENA ANITA (ATC)
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:ANITA
Last Name:SHAH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 OLD TAMPA HWY
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-1135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4440 OLD TAMPA HWY
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-1135
Practice Address - Country:US
Practice Address - Phone:999-999-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL65252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer