Healthcare Provider Details

I. General information

NPI: 1962350991
Provider Name (Legal Business Name): SHANNON REYES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22395 EDGEWATER DR
PORT CHARLOTTE FL
33980-2012
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 941-766-7222
  • Fax: 866-504-5536
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11047888
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: