Provider Demographics
NPI:1043558331
Name:KING, SHANNON (ADN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:ADN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 TARGET LN NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3065
Mailing Address - Country:US
Mailing Address - Phone:505-550-7303
Mailing Address - Fax:
Practice Address - Street 1:8200 GUADALUPE TRL NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87114-1121
Practice Address - Country:US
Practice Address - Phone:505-898-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR52018163WS0200X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WS0200XNursing Service ProvidersRegistered NurseSchool