Provider Demographics
NPI:1134413438
Name:BLACK, SHANNON NICHOLE (DC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:NICHOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3669 REBECCA LN
Mailing Address - Street 2:APT A
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5084
Mailing Address - Country:US
Mailing Address - Phone:765-585-3996
Mailing Address - Fax:
Practice Address - Street 1:3803 PALMER PARK BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2600
Practice Address - Country:US
Practice Address - Phone:719-443-0750
Practice Address - Fax:719-634-4538
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6689111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor