Provider Demographics
NPI:1396493789
Name:JENNINGS, SHANNON MARIE (AGACNP-BC)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:WILDER
Other - Last Name:GERVAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11426 E PETRA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-1964
Mailing Address - Country:US
Mailing Address - Phone:504-909-3872
Mailing Address - Fax:
Practice Address - Street 1:2024 S BALDWIN UNIT 76
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-1706
Practice Address - Country:US
Practice Address - Phone:504-909-3872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN205721163W00000X
AZ276686363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse