Provider Demographics
NPI:1962494336
Name:DAVIS, SHANNON RENE' (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RENE'
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14785 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-2496
Mailing Address - Country:US
Mailing Address - Phone:904-292-1808
Mailing Address - Fax:
Practice Address - Street 1:14785 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2496
Practice Address - Country:US
Practice Address - Phone:904-292-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14524235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist