Provider Demographics
NPI:1376912063
Name:DOMFORT, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DOMFORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31840 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3713
Mailing Address - Country:US
Mailing Address - Phone:727-202-9200
Mailing Address - Fax:
Practice Address - Street 1:31840 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3713
Practice Address - Country:US
Practice Address - Phone:727-202-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT20621225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics