Provider Demographics
NPI:1558478412
Name:FRAZIER, SHANNON (ARNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 13TH AVE S
Mailing Address - Street 2:STE 216
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3230
Mailing Address - Country:US
Mailing Address - Phone:904-246-8480
Mailing Address - Fax:904-246-8578
Practice Address - Street 1:1370 13TH AVE S
Practice Address - Street 2:STE 216
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3230
Practice Address - Country:US
Practice Address - Phone:904-246-8480
Practice Address - Fax:904-246-8578
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3253072363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27131870Medicaid