Provider Demographics
NPI:1063981892
Name:GILLON, CANISHA SHANARA (PMHNP)
Entity type:Individual
Prefix:MS
First Name:CANISHA
Middle Name:SHANARA
Last Name:GILLON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 BONITA CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-7224
Mailing Address - Country:US
Mailing Address - Phone:407-486-2085
Mailing Address - Fax:
Practice Address - Street 1:330 KAY LARKIN DR
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-2307
Practice Address - Country:US
Practice Address - Phone:386-329-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-22
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP000536363LP0808X
FL9328108363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health