Provider Demographics
NPI:1255819009
Name:BURNEY, SHAVON CHANTA
Entity type:Individual
Prefix:
First Name:SHAVON
Middle Name:CHANTA
Last Name:BURNEY
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 1:4575 SE DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6826
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:12337 WYNNFIELD LAKES DR UNIT 1721
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4272
Practice Address - Country:US
Practice Address - Phone:386-383-0251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other