Healthcare Provider Details

I. General information

NPI: 1093073041
Provider Name (Legal Business Name): SHANNON MARIE MICHAUD FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WILLOW CREEK RD STE 2200
PRESCOTT AZ
86301-1614
US

IV. Provider business mailing address

PO BOX 10880
PRESCOTT AZ
86304-0880
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-6025
  • Fax: 928-778-3026
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number272010
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704245947
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: