Healthcare Provider Details

I. General information

NPI: 1619198264
Provider Name (Legal Business Name): SHANNON LISE HOSIE MS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4952 HOOK HOLLOW CIR
ORLANDO FL
32837-4903
US

IV. Provider business mailing address

4952 HOOK HOLLOW CIR
ORLANDO FL
32837-4903
US

V. Phone/Fax

Practice location:
  • Phone: 631-806-2467
  • Fax:
Mailing address:
  • Phone: 631-806-2467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number30839
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number021088
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: