Provider Demographics
NPI:1902146327
Name:GONZALES, SHANNON (CNM)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 BLANCA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2340
Mailing Address - Country:US
Mailing Address - Phone:719-587-1417
Mailing Address - Fax:719-587-6324
Practice Address - Street 1:106 BLANCA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2340
Practice Address - Country:US
Practice Address - Phone:719-589-8082
Practice Address - Fax:719-589-8086
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO990648367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife