Basic Information
| Provider Information | |||||||||
| NPI: | 1154884815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCGINLEY-VALLEE | ||||||||
| FirstName: | SHANNEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 S WOODS DR | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216363066 | ||||||||
| FaxNumber: | 3216362545 | ||||||||
| Practice Location | |||||||||
| Address1: | 8057 SPYGLASS HILL RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214359800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2019 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS18776 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 114735600 | 05 | FL | MEDICAID |