Provider Demographics
NPI:1528403987
Name:BOHNERT, SHANNON L (DPM)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:BOHNERT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13600 ICOT BLVD BLDG B
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-9703
Mailing Address - Country:US
Mailing Address - Phone:888-290-6321
Mailing Address - Fax:727-669-8417
Practice Address - Street 1:13600 ICOT BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-9703
Practice Address - Country:US
Practice Address - Phone:888-290-6321
Practice Address - Fax:727-669-8417
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3796213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist