Healthcare Provider Details

I. General information

NPI: 1124428537
Provider Name (Legal Business Name): SHANNON ELAAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 DOUGLAS AVE SUITE 208
ALTAMONTE SPRINGS FL
32714-5206
US

IV. Provider business mailing address

801 DOUGLAS AVE SUITE 208
ALTAMONTE SPRINGS FL
32714
US

V. Phone/Fax

Practice location:
  • Phone: 407-830-6412
  • Fax:
Mailing address:
  • Phone: 407-830-6412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: