Provider Demographics
NPI:1255785515
Name:POWELL, SHANNON (FNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19246 E IDAHO PL
Mailing Address - Street 2:UNIT 103
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80017-6360
Mailing Address - Country:US
Mailing Address - Phone:719-440-4148
Mailing Address - Fax:
Practice Address - Street 1:5799 STETSON HILLS BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-4223
Practice Address - Country:US
Practice Address - Phone:719-471-2273
Practice Address - Fax:719-380-0228
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017791363LF0000X
CT10256363LF0000X, 363LP0808X
CO0992329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80420257Medicaid
CO80420257Medicaid