Provider Demographics
NPI:1427560820
Name:CANNON STANSBURY, SHELLY L (AGCNS-BC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:CANNON STANSBURY
Suffix:
Gender:F
Credentials:AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1943 INTERLOCKEN DR
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-8952
Mailing Address - Country:US
Mailing Address - Phone:303-670-2847
Mailing Address - Fax:
Practice Address - Street 1:8300 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6005
Practice Address - Country:US
Practice Address - Phone:303-425-8506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0993473-CNS364SP2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperative
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0993473-CNSOtherAPN LICENSE