Healthcare Provider Details

I. General information

NPI: 1104755974
Provider Name (Legal Business Name): SHANNON RAE HURST LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SEAGATE AVE APT 258
NEPTUNE BEACH FL
32266-3521
US

IV. Provider business mailing address

1100 SEAGATE AVE APT 258
NEPTUNE BEACH FL
32266-3521
US

V. Phone/Fax

Practice location:
  • Phone: 904-898-0263
  • Fax:
Mailing address:
  • Phone: 904-898-0263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberPN1346211
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: