Provider Demographics
NPI:1346545852
Name:BRANSON, SHANNON (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRANSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8405 POYDRAS LANE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635
Mailing Address - Country:US
Mailing Address - Phone:813-480-7001
Mailing Address - Fax:
Practice Address - Street 1:15241 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1823
Practice Address - Country:US
Practice Address - Phone:813-480-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 52640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist