Provider Demographics
NPI:1326607755
Name:BORTOLOTTO, SHANNON JOHNSON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JOHNSON
Last Name:BORTOLOTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 JULIAN ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-1610
Mailing Address - Country:US
Mailing Address - Phone:720-848-0945
Mailing Address - Fax:
Practice Address - Street 1:4200 JULIAN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-1610
Practice Address - Country:US
Practice Address - Phone:720-848-0945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0106859364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist