Provider Demographics
NPI:1780427518
Name:VASQUEZ, SHANNON J (FNP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:J
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CALLEJON LAS ANIMAS
Mailing Address - Street 2:
Mailing Address - City:GLORIETA
Mailing Address - State:NM
Mailing Address - Zip Code:87535-7040
Mailing Address - Country:US
Mailing Address - Phone:505-819-9002
Mailing Address - Fax:
Practice Address - Street 1:6 CALLEJON LAS ANIMAS
Practice Address - Street 2:
Practice Address - City:GLORIETA
Practice Address - State:NM
Practice Address - Zip Code:87535-7040
Practice Address - Country:US
Practice Address - Phone:505-819-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-80565363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner