Provider Demographics
NPI:1265002919
Name:HUMPHREY, SHANNON MARIE (APRN, CPNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:APRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:277 BUDDY GANEM DR STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-3202
Mailing Address - Country:US
Mailing Address - Phone:361-777-3900
Mailing Address - Fax:361-413-0274
Practice Address - Street 1:9139 WESTOVER HILLS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-2889
Practice Address - Country:US
Practice Address - Phone:210-437-3990
Practice Address - Fax:210-437-3991
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1045865363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics