Provider Demographics
NPI:1245709179
Name:DANIEL, SHANNON KAY (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAY
Last Name:DANIEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N PENNSYLVANIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4758
Mailing Address - Country:US
Mailing Address - Phone:575-623-9101
Mailing Address - Fax:
Practice Address - Street 1:400 N PENNSYLVANIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4758
Practice Address - Country:US
Practice Address - Phone:575-623-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24391363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner