Provider Demographics
NPI:1306689468
Name:EDWARDS, SHANNON MARGARET
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARGARET
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2637 SW FAIR ISLE RD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2093
Mailing Address - Country:US
Mailing Address - Phone:772-446-2040
Mailing Address - Fax:
Practice Address - Street 1:2637 SW FAIR ISLE RD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2093
Practice Address - Country:US
Practice Address - Phone:772-446-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13887310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility