Provider Demographics
NPI:1356645352
Name:LARGE, SHANNON (ARNP, DNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:LARGE
Suffix:
Gender:F
Credentials:ARNP, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 SW 13TH STREET
Mailing Address - Street 2:FLORIDA RECOVERY CENTER
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608
Mailing Address - Country:US
Mailing Address - Phone:352-265-5534
Mailing Address - Fax:
Practice Address - Street 1:4001 SW 13TH STREET
Practice Address - Street 2:FLORIDA RECOVERY CENTER
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608
Practice Address - Country:US
Practice Address - Phone:352-265-5534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9264277363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009198200Medicaid
FLHK133ZMedicare PIN