Provider Demographics
NPI:1457828899
Name:MIMS, SHANNON LEIGH
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEIGH
Last Name:MIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEIGH
Other - Last Name:ORAMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:19581 LANSHELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917
Mailing Address - Country:US
Mailing Address - Phone:703-582-5630
Mailing Address - Fax:
Practice Address - Street 1:12670 WHITEHALL DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3619
Practice Address - Country:US
Practice Address - Phone:239-936-3554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9363950363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner