Provider Demographics
NPI:1851690739
Name:MCKINNIE, SHANNON LEA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:LEA
Last Name:MCKINNIE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 SW 32ND CT
Mailing Address - Street 2:
Mailing Address - City:WEST PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-5757
Mailing Address - Country:US
Mailing Address - Phone:954-987-8454
Mailing Address - Fax:
Practice Address - Street 1:3300 SW 32ND CT
Practice Address - Street 2:
Practice Address - City:WEST PARK
Practice Address - State:FL
Practice Address - Zip Code:33023-5757
Practice Address - Country:US
Practice Address - Phone:954-987-8454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7479235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist