Provider Demographics
NPI:1184134462
Name:HOPSON, SHANTA TAMIKA (APN)
Entity type:Individual
Prefix:
First Name:SHANTA
Middle Name:TAMIKA
Last Name:HOPSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1821
Mailing Address - Country:US
Mailing Address - Phone:815-381-7250
Mailing Address - Fax:815-381-7251
Practice Address - Street 1:1502 PARKVIEW AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1821
Practice Address - Country:US
Practice Address - Phone:815-381-7250
Practice Address - Fax:815-381-7251
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016322363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner