Provider Demographics
NPI:1821649211
Name:MUNZ, SHANNON TRACY
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:TRACY
Last Name:MUNZ
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 1:136 8TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3616
Mailing Address - Country:US
Mailing Address - Phone:561-856-8040
Mailing Address - Fax:
Practice Address - Street 1:203 N MARION ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602
Practice Address - Country:US
Practice Address - Phone:813-474-9804
Practice Address - Fax:813-540-6025
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004145363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily