Provider Demographics
NPI:1104038868
Name:LUNDBERG, SHAWN KELLY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:SHAWN
Middle Name:KELLY
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5399
Mailing Address - Country:US
Mailing Address - Phone:352-728-3898
Mailing Address - Fax:352-728-6240
Practice Address - Street 1:1414 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5399
Practice Address - Country:US
Practice Address - Phone:352-728-3898
Practice Address - Fax:352-728-6240
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2120182363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS96428Medicare UPIN
FLE3491ZMedicare ID - Type Unspecified