Basic Information
| Provider Information | |||||||||
| NPI: | 1215490776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILIPPS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 170 ROCKSPRAY RDG | ||||||||
| Address2: | |||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302692489 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2627 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043087372 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2019 | ||||||||
| 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 | 390200000X | UO7417 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | OS18839 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.