Provider Demographics
NPI:1659766244
Name:WEBER, SHANNON ROSE (ARNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:WEBER
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 1:18550 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6751
Mailing Address - Country:US
Mailing Address - Phone:352-735-3755
Mailing Address - Fax:352-735-3151
Practice Address - Street 1:18550 US HIGHWAY 441 STE A
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6751
Practice Address - Country:US
Practice Address - Phone:352-735-3755
Practice Address - Fax:352-735-3151
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3360292363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021028900Medicaid