Provider Demographics
NPI:1922553908
Name:STADELMANN, SHANNON D (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:STADELMANN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:DOERSAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:MAIL DROP 4S-205
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:760-479-3900
Mailing Address - Fax:760-634-4845
Practice Address - Street 1:477 N EL CAMINO REAL
Practice Address - Street 2:SUITE 208A
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1328
Practice Address - Country:US
Practice Address - Phone:760-479-3900
Practice Address - Fax:760-634-4845
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004762363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily