Provider Demographics
NPI:1639611833
Name:SHANNON, GEORGIA
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:SHANNON
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 1:5515 CLARCONA POINTE WAY APT 707
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-3275
Mailing Address - Country:US
Mailing Address - Phone:941-565-9949
Mailing Address - Fax:
Practice Address - Street 1:5515 CLARCONA POINTE WAY APT 707
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-3275
Practice Address - Country:US
Practice Address - Phone:941-565-9949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-06
Last Update Date:2016-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X, 372600000X, 3747A0650X, 3747P1801X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide