Provider Demographics
NPI:1346570983
Name:NELSON, SHANNON LYN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LYN
Last Name:NELSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LYN
Other - Last Name:PECKHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1412 FLORA AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:LEHIGH
Mailing Address - State:FL
Mailing Address - Zip Code:33971
Mailing Address - Country:US
Mailing Address - Phone:239-233-1354
Mailing Address - Fax:
Practice Address - Street 1:1441 METROPOLIS AVENUE
Practice Address - Street 2:
Practice Address - City:FT. MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:239-561-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6198235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist