Provider Demographics
NPI:1699668772
Name:SHAULIS, MISTY D (PTA)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:D
Last Name:SHAULIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6109 E MILTON RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-7920
Mailing Address - Country:US
Mailing Address - Phone:334-465-5088
Mailing Address - Fax:334-465-5088
Practice Address - Street 1:1921 ORTEGA ST
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-4111
Practice Address - Country:US
Practice Address - Phone:850-936-8919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL33696225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant