Provider Demographics
NPI:1215583059
Name:QUINN, SHANNON WILKES (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:WILKES
Last Name:QUINN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:WILKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:4624 S HOLLADAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7056
Mailing Address - Country:US
Mailing Address - Phone:801-277-2682
Mailing Address - Fax:
Practice Address - Street 1:4624 S HOLLADAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-7056
Practice Address - Country:US
Practice Address - Phone:801-277-2682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9062677-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily