Provider Demographics
NPI:1154884815
Name:MCGINLEY-VALLEE, SHANNEN M (DO)
Entity type:Individual
Prefix:DR
First Name:SHANNEN
Middle Name:M
Last Name:MCGINLEY-VALLEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 S WOODS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3262
Mailing Address - Country:US
Mailing Address - Phone:321-636-3066
Mailing Address - Fax:321-636-2545
Practice Address - Street 1:8057 SPYGLASS HILL RD STE 102
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8565
Practice Address - Country:US
Practice Address - Phone:321-435-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS18776208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114735600Medicaid