Provider Demographics
NPI:1205693801
Name:KAZMAN, SHANNON L (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:KAZMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-5679
Mailing Address - Country:US
Mailing Address - Phone:260-414-6602
Mailing Address - Fax:
Practice Address - Street 1:1490 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-5679
Practice Address - Country:US
Practice Address - Phone:260-414-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11031223363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner