Provider Demographics
NPI:1164961678
Name:HORNSBY, SHANNON BRYANT (AG-APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:BRYANT
Last Name:HORNSBY
Suffix:
Gender:F
Credentials:AG-APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:
Practice Address - Street 1:1150 N 35TH AVE STE 440
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5430
Practice Address - Country:US
Practice Address - Phone:954-265-6356
Practice Address - Fax:954-985-5154
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9352328363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020121200Medicaid