Provider Demographics
NPI:1619222684
Name:COYLE, SHANNON (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:COYLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W MACCLENNY AVE
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2029
Mailing Address - Country:US
Mailing Address - Phone:904-571-9218
Mailing Address - Fax:
Practice Address - Street 1:121 W MACCLENNY AVE
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2029
Practice Address - Country:US
Practice Address - Phone:904-259-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9248323363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01112815OtherRAILROAD MEDICARE - FL
FLGJ086XMedicare PIN