Healthcare Provider Details

I. General information

NPI: 1023654647
Provider Name (Legal Business Name): MICAELA RAE SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICAELA RAE CAMPBELL

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7016 NORMANDY BLVD
JACKSONVILLE FL
32205-6206
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 904-783-2405
  • Fax: 904-420-6101
Mailing address:
  • Phone: 877-856-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11015772
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN9469517
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11015772
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: