Healthcare Provider Details

I. General information

NPI: 1255968954
Provider Name (Legal Business Name): SHANNON KOLUPAEVA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON ENLOE

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 LAKESHORE DR
BIRMINGHAM AL
35229-0002
US

IV. Provider business mailing address

5400 BROOKMEADOW LN
RENO NV
89511-9000
US

V. Phone/Fax

Practice location:
  • Phone: 775-560-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1-166204
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number64423
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: