Provider Demographics
NPI:1902586886
Name:SMITH, SHANNON (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15281 S 182ND LN
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-3648
Mailing Address - Country:US
Mailing Address - Phone:602-615-9376
Mailing Address - Fax:
Practice Address - Street 1:700 N ESTRELLA PKWY STE 110
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9250
Practice Address - Country:US
Practice Address - Phone:623-877-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ295423363LF0000X
AZRNP295423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily