Provider Demographics
NPI:1457243743
Name:MALONEY, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MALONEY
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 1:1633 ARMIN CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-7309
Mailing Address - Country:US
Mailing Address - Phone:386-882-0001
Mailing Address - Fax:
Practice Address - Street 1:208 BOOTH RD STE D
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5718
Practice Address - Country:US
Practice Address - Phone:407-906-3755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-19
Last Update Date:2025-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11040954363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health