Provider Demographics
NPI:1427719657
Name:KEEGAN, SHANNON MALLORY (FNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MALLORY
Last Name:KEEGAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MALLORY
Other - Last Name:GAETJENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:815 CHENEY HWY
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6960
Mailing Address - Country:US
Mailing Address - Phone:321-567-4237
Mailing Address - Fax:
Practice Address - Street 1:519 N DIXIE FWY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6707
Practice Address - Country:US
Practice Address - Phone:407-299-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11016157363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner