Healthcare Provider Details

I. General information

NPI: 1376912063
Provider Name (Legal Business Name): SHANNON DOMFORT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 4TH ST N STE B
SAINT PETERSBURG FL
33703-4735
US

IV. Provider business mailing address

4200 4TH ST N STE B
SAINT PETERSBURG FL
33703-4735
US

V. Phone/Fax

Practice location:
  • Phone: 727-592-5417
  • Fax:
Mailing address:
  • Phone: 727-592-5417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT20621
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: