Provider Demographics
NPI:1538365341
Name:POWELL, SHANNON BRUNSON (PA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:BRUNSON
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2966 CHASE WAY
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-6458
Mailing Address - Country:US
Mailing Address - Phone:850-482-5777
Mailing Address - Fax:850-718-2551
Practice Address - Street 1:4250 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-1917
Practice Address - Country:US
Practice Address - Phone:850-718-2580
Practice Address - Fax:850-718-2551
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL395902471C3402X
FL07FL1280363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant