Provider Demographics
NPI:1194539874
Name:SIMON, SHANNON (LPN/NRP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:LPN/NRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13234 GREAT PLAINS DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-9437
Mailing Address - Country:US
Mailing Address - Phone:734-891-2396
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-5023
Practice Address - Country:US
Practice Address - Phone:813-828-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians