Provider Demographics
NPI:1356452627
Name:BASHAM, SHANNON MARIE (AUD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:BASHAM
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 A1A N
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3287
Mailing Address - Country:US
Mailing Address - Phone:904-273-2232
Mailing Address - Fax:
Practice Address - Street 1:830 A1A N
Practice Address - Street 2:SUITE 1
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3287
Practice Address - Country:US
Practice Address - Phone:904-273-2232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY 1361231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist