Healthcare Provider Details

I. General information

NPI: 1639612096
Provider Name (Legal Business Name): SHANNON MAE SCOLLY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 ADOBE CIR
JUPITER FL
33458-8008
US

IV. Provider business mailing address

126 ADOBE CIR
JUPITER FL
33458-8008
US

V. Phone/Fax

Practice location:
  • Phone: 617-775-4228
  • Fax:
Mailing address:
  • Phone: 617-775-4228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR9440334
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001228008
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP 9440334
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: