Healthcare Provider Details

I. General information

NPI: 1639611833
Provider Name (Legal Business Name): GEORGIA SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2016
Last Update Date: 11/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5515 CLARCONA POINTE WAY APT 707
ORLANDO FL
32810-3275
US

IV. Provider business mailing address

5515 CLARCONA POINTE WAY APT 707
ORLANDO FL
32810-3275
US

V. Phone/Fax

Practice location:
  • Phone: 941-565-9949
  • Fax:
Mailing address:
  • Phone: 941-565-9949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: