Provider Demographics
NPI:1083120760
Name:ROPER, SHANNON L (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:ROPER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S HALAGUENO ST STE 8
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5748
Mailing Address - Country:US
Mailing Address - Phone:575-725-5211
Mailing Address - Fax:575-725-5212
Practice Address - Street 1:110 S HALAGUENO ST STE 8
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5748
Practice Address - Country:US
Practice Address - Phone:575-255-2117
Practice Address - Fax:575-725-5212
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP03456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily