Provider Demographics
NPI:1598118358
Name:SHIELDS, SHANNON MARY (FNP)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARY
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:MARY
Other - Last Name:VAN MARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5870 HIATUS RD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-6424
Mailing Address - Country:US
Mailing Address - Phone:888-447-2462
Mailing Address - Fax:865-560-7110
Practice Address - Street 1:14699 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-3903
Practice Address - Country:US
Practice Address - Phone:888-447-2362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20357363LF0000X
CO0001762363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily