Healthcare Provider Details

I. General information

NPI: 1063981892
Provider Name (Legal Business Name): CANISHA SHANARA GILLON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2018
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 1ST ST S
WINTER HAVEN FL
33880-3904
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 863-294-7062
  • Fax:
Mailing address:
  • Phone: 727-532-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9328108
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: