Provider Demographics
NPI:1700160694
Name:SHANNON, KIMBERLY EVETTE (RPH)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:EVETTE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 8TH AVE W
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-4712
Mailing Address - Country:US
Mailing Address - Phone:941-729-5250
Mailing Address - Fax:941-729-7899
Practice Address - Street 1:2817 2ND STREET EAST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208
Practice Address - Country:US
Practice Address - Phone:941-782-7024
Practice Address - Fax:833-374-2750
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS30747183500000X
311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No183500000XPharmacy Service ProvidersPharmacist