Healthcare Provider Details

I. General information

NPI: 1588117717
Provider Name (Legal Business Name): SHANNON M SHAFFER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2016
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 PARTERRE AVE
FOOTHILL RANCH CA
92610-2351
US

IV. Provider business mailing address

MINDPATH HEALTH 3 CORPORATE PARK, STE 170
IRVINE CA
92606-8439
US

V. Phone/Fax

Practice location:
  • Phone: 619-890-4786
  • Fax:
Mailing address:
  • Phone: 619-890-4786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95011972
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number113172
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6919
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: