Provider Demographics
NPI:1841739018
Name:BOODHWANI, SHANNON (AGNP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BOODHWANI
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:WILLENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2450 GOODLETTE-FRANK RD N STE 101
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-4595
Mailing Address - Country:US
Mailing Address - Phone:239-624-8470
Mailing Address - Fax:
Practice Address - Street 1:2450 GOODLETTE-FRANK RD N STE 101
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-4595
Practice Address - Country:US
Practice Address - Phone:239-624-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11018802363LG0600X
TXAP133009363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114708500Medicaid
FLMI6GDOtherFL BLUE