Provider Demographics
NPI:1003064858
Name:PIPPIN, SHANNON RAE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:PIPPIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5512 37TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-6825
Mailing Address - Country:US
Mailing Address - Phone:352-209-6884
Mailing Address - Fax:941-487-5430
Practice Address - Street 1:5512 37TH AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-6825
Practice Address - Country:US
Practice Address - Phone:352-209-6884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000471100Medicaid
FL006703300Medicaid