Healthcare Provider Details

I. General information

NPI: 1659034064
Provider Name (Legal Business Name): SHANDA BISHOP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29658 DOUGLAS RD
DAPHNE AL
36526-9533
US

IV. Provider business mailing address

7900 E UNION AVE STE 1100
DENVER CO
80237-2746
US

V. Phone/Fax

Practice location:
  • Phone: 251-895-3066
  • Fax:
Mailing address:
  • Phone: 212-369-6757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0003344-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: