Provider Demographics
NPI:1144686312
Name:HEUKLOM, SHANNON (MSN, MPH, AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HEUKLOM
Suffix:
Gender:F
Credentials:MSN, MPH, AGPCNP-BC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:STAPLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 ELLIS ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-2735
Mailing Address - Country:US
Mailing Address - Phone:415-674-6140
Mailing Address - Fax:
Practice Address - Street 1:330 ELLIS ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-2735
Practice Address - Country:US
Practice Address - Phone:401-440-8056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003581363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health