Healthcare Provider Details

I. General information

NPI: 1790196087
Provider Name (Legal Business Name): SHANNON JAMES WORTHY ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON JAMES BREININGER APRN

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-1771
  • Fax: 321-434-1775
Mailing address:
  • Phone: 321-434-1771
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN916975
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: