Provider Demographics
NPI:1255956512
Name:WAGNER, SHANNON MICHELLE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-0660
Mailing Address - Country:US
Mailing Address - Phone:970-328-8840
Mailing Address - Fax:855-848-8829
Practice Address - Street 1:551 BROADWAY
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631
Practice Address - Country:US
Practice Address - Phone:970-328-8840
Practice Address - Fax:855-848-8829
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1625641163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse