Healthcare Provider Details

I. General information

NPI: 1922458835
Provider Name (Legal Business Name): SHANNON NICOLE STANLEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 N ORANGE BLOSSOM TRL
KISSIMMEE FL
34744-2316
US

IV. Provider business mailing address

2501 N ORANGE AVE STE 182
ORLANDO FL
32804-4675
US

V. Phone/Fax

Practice location:
  • Phone: 407-846-4343
  • Fax: 317-705-5047
Mailing address:
  • Phone: 407-303-2030
  • Fax: 407-303-2042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9277304
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: