MEDICARE: SHANNA PROUDFIT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		FL
2	106S00000X	Behavior Technician	RBT-18-49965	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144629320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNA PROUDFIT

Provider Business Mailing Address
First Line	:	12920 SW 133RD CT UNIT 11
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-6149
Country	:	US
Telephone Number	:	786-475-5732
Fax Number	:	844-455-3224

Provider Business Practice Location Address
First Line	:	12920 SW 133RD CT UNIT 11
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-6149
Country	:	US
Telephone Number	:	786-475-5732
Fax Number	:	844-455-3224

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	03/19/2024

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Directions to “ SHANNA PROUDFIT ” Practice Location

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