Provider Demographics
NPI:1578391058
Name:DEPENZA, SHANNON IRENE (CCM)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:IRENE
Last Name:DEPENZA
Suffix:
Gender:F
Credentials:CCM
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:IRENE
Other - Last Name:DEPENZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCM
Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5005
Mailing Address - Country:US
Mailing Address - Phone:904-542-9947
Mailing Address - Fax:888-410-0935
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5005
Practice Address - Country:US
Practice Address - Phone:904-542-9947
Practice Address - Fax:888-410-0935
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3298632171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty