Healthcare Provider Details

I. General information

NPI: 1134118995
Provider Name (Legal Business Name): SHANNON PATRICE VALENZUELA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13634 N. 93RD AVE SUITE 100
PEORIA AZ
85381
US

IV. Provider business mailing address

13634 N. 93RD AVE SUITE 100
PEORIA AZ
85381
US

V. Phone/Fax

Practice location:
  • Phone: 623-933-0301
  • Fax: 623-933-0224
Mailing address:
  • Phone: 623-933-0301
  • Fax: 623-933-0224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number22718
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22718
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: