Provider Demographics
NPI:1548313711
Name:RUDOLPH, SHANNON MICHIYO (DC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MICHIYO
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 NW 43RD ST
Mailing Address - Street 2:STE 7B
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6632
Mailing Address - Country:US
Mailing Address - Phone:352-872-5095
Mailing Address - Fax:352-872-5097
Practice Address - Street 1:4400 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6580
Practice Address - Country:US
Practice Address - Phone:352-371-4120
Practice Address - Fax:352-371-3378
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9069111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor