Provider Demographics
NPI:1689166019
Name:HARVEY, SHANNON RAE (OD)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:RAE
Last Name:HARVEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 W EVANS ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-3429
Mailing Address - Country:US
Mailing Address - Phone:843-669-4156
Mailing Address - Fax:843-664-2121
Practice Address - Street 1:367 W EVANS ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-3429
Practice Address - Country:US
Practice Address - Phone:843-669-4156
Practice Address - Fax:843-664-2121
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2049OtherOPTOMETRY LICENSE
SCD20494Medicaid