Healthcare Provider Details

I. General information

NPI: 1265296925
Provider Name (Legal Business Name): SHANNON MILLER MOULTON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14055 RIVEREDGE DR STE 250
TAMPA FL
33637-2141
US

IV. Provider business mailing address

2600 BRUCE B DOWNS BLVD
WESLEY CHAPEL FL
33544-9207
US

V. Phone/Fax

Practice location:
  • Phone: 813-929-5451
  • Fax: 813-929-5465
Mailing address:
  • Phone: 813-446-5780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11031067
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN11031067
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: