Provider Demographics
NPI:1225513591
Name:LANGE, SHANNON LESLEY (CPNP-PC, CNS)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:LESLEY
Last Name:LANGE
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Gender:F
Credentials:CPNP-PC, CNS
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Mailing Address - Street 1:19TH MEDICAL GROUP 1090 ARNOLD DRIVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK AFB
Mailing Address - State:AR
Mailing Address - Zip Code:72099-4933
Mailing Address - Country:US
Mailing Address - Phone:501-987-7446
Mailing Address - Fax:
Practice Address - Street 1:BROOKE ARMY MEDICAL CENTER
Practice Address - Street 2:3551 ROGER BROOKE DRIVE
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2023-08-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CANP95009977208000000X
TX1013771363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics