Provider Demographics
NPI:1629670096
Name:LIGHT, SHANA
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:LIGHT
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 1:1906 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4259
Mailing Address - Country:US
Mailing Address - Phone:970-384-7033
Mailing Address - Fax:970-384-8174
Practice Address - Street 1:978 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-1820
Practice Address - Country:US
Practice Address - Phone:970-963-3350
Practice Address - Fax:970-963-2958
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0995947-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily