Provider Demographics
NPI:1376037374
Name:MITCHELL, SHANNON M (APRN)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:M
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S STATE ROAD 7 SUITE 104-342
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:561-289-4642
Mailing Address - Fax:561-257-1154
Practice Address - Street 1:125 S STATE ROAD 7 SUITE 104-342
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-289-4642
Practice Address - Fax:561-257-1154
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2023-12-22
Deactivation Date:2019-09-26
Deactivation Code:
Reactivation Date:2019-10-10
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9228410363LF0000X, 261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Single Specialty
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103700600Medicaid