Provider Demographics
NPI:1881969301
Name:WELLS, SHANNON (LPN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:LPN
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 DD
Mailing Address - Street 2:401 N. DOLORES ROAD
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321
Mailing Address - Country:US
Mailing Address - Phone:970-565-1150
Mailing Address - Fax:970-564-1654
Practice Address - Street 1:401 N DOLORES RD
Practice Address - Street 2:PO BOX DD
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-4213
Practice Address - Country:US
Practice Address - Phone:970-565-1150
Practice Address - Fax:970-564-1654
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15234164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse