Provider Demographics
NPI:1902162019
Name:INGWERSEN, SHANNON TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:TAYLOR
Last Name:INGWERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E HIBISCUS BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3155
Mailing Address - Country:US
Mailing Address - Phone:321-724-2229
Mailing Address - Fax:321-728-6681
Practice Address - Street 1:330 E HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3155
Practice Address - Country:US
Practice Address - Phone:321-724-2229
Practice Address - Fax:321-728-6668
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0056592207V00000X
FLME149728207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology