Provider Demographics
NPI:1710372511
Name:DUNN, SHANNON BROCKMAN (MD, RDN, IBCLC, FAAP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:BROCKMAN
Last Name:DUNN
Suffix:
Gender:F
Credentials:MD, RDN, IBCLC, FAAP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ELIZABETH
Other - Last Name:BROCKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, RDN, IBCLC, FAAP
Mailing Address - Street 1:83 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:83 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2031
Practice Address - Country:US
Practice Address - Phone:321-843-9792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLTRN348332080N0001X
VA0101261265208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101261265OtherMEDICAL LICENSE