Healthcare Provider Details

I. General information

NPI: 1528786050
Provider Name (Legal Business Name): EMILY GRACE SHANNON CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 MILLENIA BLVD STE 500
ORLANDO FL
32839-6019
US

IV. Provider business mailing address

4700 MILLENIA BLVD STE 500
ORLANDO FL
32839-6019
US

V. Phone/Fax

Practice location:
  • Phone: 407-349-8353
  • Fax: 720-640-0405
Mailing address:
  • Phone: 407-349-8353
  • Fax: 720-640-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: