Provider Demographics
NPI:1073144994
Name:VONGKHANKEO, SHANA LEE (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:LEE
Last Name:VONGKHANKEO
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N ALAFAYA TRL STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-4316
Mailing Address - Country:US
Mailing Address - Phone:407-282-4400
Mailing Address - Fax:
Practice Address - Street 1:250 N ALAFAYA TRL STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4316
Practice Address - Country:US
Practice Address - Phone:407-282-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005527363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105858200Medicaid