Provider Demographics
NPI:1255968954
Name:KOLUPAEVA, SHANNON (RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KOLUPAEVA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:ENLOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5400 BROOKMEADOW LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-9000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35229-0002
Practice Address - Country:US
Practice Address - Phone:775-560-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-166204163WC0200X
ID64423367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine