Provider Demographics
NPI:1629036066
Name:PARKER, SHANNON -
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:-
Last Name:PARKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S RENELLIE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2531
Mailing Address - Country:US
Mailing Address - Phone:813-287-8581
Mailing Address - Fax:
Practice Address - Street 1:212 S RENELLIE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2531
Practice Address - Country:US
Practice Address - Phone:813-287-8581
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA30663225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist