Provider Demographics
NPI:1851125462
Name:WATERS-MITCHELL, SHANNON THERESA
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:THERESA
Last Name:WATERS-MITCHELL
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 1:40946 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-5446
Mailing Address - Country:US
Mailing Address - Phone:727-504-4969
Mailing Address - Fax:
Practice Address - Street 1:617 PALM AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-2426
Practice Address - Country:US
Practice Address - Phone:727-504-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach