Provider Demographics
NPI:1760114334
Name:RESTO, SHANNON G (NNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:G
Last Name:RESTO
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 COTTONWOOD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814-9710
Mailing Address - Country:US
Mailing Address - Phone:405-501-4784
Mailing Address - Fax:
Practice Address - Street 1:11432 NW 101ST ST
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-7463
Practice Address - Country:US
Practice Address - Phone:405-501-4784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK209617363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care