Provider Demographics
NPI:1891121539
Name:THOMPSON, SHANNON TILLAR (DNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:TILLAR
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:RENE'
Other - Last Name:TILLAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:904-354-6868
Mailing Address - Fax:904-358-3067
Practice Address - Street 1:1714 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4404
Practice Address - Country:US
Practice Address - Phone:904-354-6868
Practice Address - Fax:904-358-3067
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11005212363LP0200X, 363LP0200X
VA0001229514163W00000X
CA95000138363LP0200X
VA0024170271363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108111800Medicaid