Provider Demographics
NPI:1962033670
Name:GIBSON, SHANON T
Entity Type:Individual
Prefix:
First Name:SHANON
Middle Name:T
Last Name:GIBSON
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 1:1044 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-8115
Mailing Address - Country:US
Mailing Address - Phone:407-766-0884
Mailing Address - Fax:
Practice Address - Street 1:1044 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-8115
Practice Address - Country:US
Practice Address - Phone:077-660-0884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106038000Medicaid