Provider Demographics
NPI:1538646963
Name:COUILLARD, SHANNON M (CLC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:COUILLARD
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10151 UNIVERSITY BLVD # 241
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-1904
Mailing Address - Country:US
Mailing Address - Phone:407-243-8571
Mailing Address - Fax:
Practice Address - Street 1:4397 WYNDCLIFF CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-3310
Practice Address - Country:US
Practice Address - Phone:407-243-8571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE259524174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN