Basic Information
| Provider Information | |||||||||
| NPI: | 1992441083 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREHM | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PITTS | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10527 SW RUFUS WALDEN RD | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324303011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508668065 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 E 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324055400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505224485 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2022 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN5234491 | FL | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.