Provider Demographics
NPI:1285034173
Name:CALLAN, SHANNON DALE (ARNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DALE
Last Name:CALLAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-4325
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:813-974-4325
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9232465363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLWXN9QOtherBLUE CROSS BLUE SHIELD
FL018480100Medicaid