Provider Demographics
NPI:1104202621
Name:GAINE, SHANNON (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GAINE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 W EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-1117
Mailing Address - Country:US
Mailing Address - Phone:650-941-8430
Mailing Address - Fax:
Practice Address - Street 1:2630 W EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-1117
Practice Address - Country:US
Practice Address - Phone:631-848-9662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily