Basic Information
Provider Information | |||||||||
NPI: | 1629400767 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OSBECK | ||||||||
FirstName: | SHANNON | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THRASHER | ||||||||
OtherFirstName: | SHANNON | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1500 CONCORD TER | ||||||||
Address2: |   | ||||||||
City: | SUNRISE | ||||||||
State: | FL | ||||||||
PostalCode: | 333232815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002433839 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3625 UNIVERSITY BLVD S | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322164207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043996111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2013 | ||||||||
LastUpdateDate: | 07/22/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | ARNP 3283912 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
ID | Type | State | Issuer | Description | 010212900 | 05 | FL |   | MEDICAID | 003141014A | 05 | GA |   | MEDICAID |