Provider Demographics
NPI:1851774962
Name:SICKLE, SHANNON ROSE (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:SICKLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1691 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2203
Mailing Address - Country:US
Mailing Address - Phone:408-287-7526
Mailing Address - Fax:
Practice Address - Street 1:1325 TRAVIS BLVD STE C
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4611
Practice Address - Country:US
Practice Address - Phone:707-398-8916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95231874163W00000X
CA95016166363LF0000X, 363LF0000X
SC21205363LF0000X
NY340290363LF0000X
AK138768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse