Provider Demographics
NPI:1578283701
Name:MCCAMMON, SHANNON ELIZABETH
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:MCCAMMON
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 1:5358 WATER VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-7957
Mailing Address - Country:US
Mailing Address - Phone:850-694-5116
Mailing Address - Fax:
Practice Address - Street 1:1607 SAINT JAMES CT # 2
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5352
Practice Address - Country:US
Practice Address - Phone:850-878-8714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021614363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily