Healthcare Provider Details

I. General information

NPI: 1245149939
Provider Name (Legal Business Name): SHANNON RENEE JANELLE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5063 TENNESSEE LAKE DR
AUBURNDALE FL
33823-5799
US

IV. Provider business mailing address

5063 TENNESSEE LAKE DR
AUBURNDALE FL
33823-5799
US

V. Phone/Fax

Practice location:
  • Phone: 760-486-3894
  • Fax:
Mailing address:
  • Phone: 760-486-3894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2026077581
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: