Provider Demographics
NPI:1912350794
Name:OSBORNE, SHANNON
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:
Last Name:OSBORNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 SW 71ST TER
Mailing Address - Street 2:APT 101
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-7037
Mailing Address - Country:US
Mailing Address - Phone:334-549-4765
Mailing Address - Fax:
Practice Address - Street 1:7500 SW 30TH ST
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-1020
Practice Address - Country:US
Practice Address - Phone:954-452-7071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL41522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer