Provider Demographics
NPI:1962980367
Name:SCHMIDT, SHELBY NICOLLE WITSCHEN (MIT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLLE WITSCHEN
Last Name:SCHMIDT
Suffix:
Gender:F
Credentials:MIT, LAT, ATC
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:NICOLLE
Other - Last Name:WITSCHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MIT, LAT, ATC
Mailing Address - Street 1:102 WOODBINE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-3538
Mailing Address - Country:US
Mailing Address - Phone:206-777-5328
Mailing Address - Fax:
Practice Address - Street 1:102 WOODBINE CIR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-3538
Practice Address - Country:US
Practice Address - Phone:206-777-5328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT61042255A2300X
FLAL54642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer