Provider Demographics
NPI:1902211857
Name:WILLIAMS, SHANNON KATHLEEN
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:WILLIAMS
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 1:4802 51ST ST W
Mailing Address - Street 2:APT 1504
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-5101
Mailing Address - Country:US
Mailing Address - Phone:941-896-2814
Mailing Address - Fax:
Practice Address - Street 1:4802 51ST ST W
Practice Address - Street 2:APT 1504
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-5101
Practice Address - Country:US
Practice Address - Phone:941-896-2814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-29
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA38442225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist