Provider Demographics
NPI:1265430664
Name:DAVIS, SHANNAN VERA (APRN)
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:VERA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHANNAN
Other - Middle Name:HARDY
Other - Last Name:HARDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:14601 HOPE CENTER LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4707
Mailing Address - Country:US
Mailing Address - Phone:239-334-7000
Mailing Address - Fax:239-334-7070
Practice Address - Street 1:14601 HOPE CENTER LOOP
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4707
Practice Address - Country:US
Practice Address - Phone:239-334-7000
Practice Address - Fax:239-334-7070
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011245363L00000X, 363LF0000X, 363LF0000X
CT004833363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113911800Medicaid
CT1265430664Medicaid
CT1265430664Medicaid
NYJ400004923Medicare PIN