Healthcare Provider Details

I. General information

NPI: 1922553908
Provider Name (Legal Business Name): SHANNON D STADELMANN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON DOERSAM NP

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 N EL CAMINO REAL SUITE 208A
ENCINITAS CA
92024-1328
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD MAIL DROP 4S-205
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 760-479-3900
  • Fax: 760-634-4845
Mailing address:
  • Phone: 760-479-3900
  • Fax: 760-634-4845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95004762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: