Provider Demographics
NPI:1881708618
Name:PROCTOR, SHANNON (RN, LAC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:RN, LAC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CHAPPABITTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:312 E YAMPA ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2945
Mailing Address - Country:US
Mailing Address - Phone:719-475-1908
Mailing Address - Fax:
Practice Address - Street 1:115 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3130
Practice Address - Country:US
Practice Address - Phone:719-572-6340
Practice Address - Fax:719-447-4791
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO163680163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)