Healthcare Provider Details

I. General information

NPI: 1750827093
Provider Name (Legal Business Name): SHANNON HOSTETTER R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 STUART AVE
ALAMOSA CO
81101-2269
US

IV. Provider business mailing address

2115 STUART AVE
ALAMOSA CO
81101-2269
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-8058
  • Fax: 719-274-6003
Mailing address:
  • Phone: 719-589-8058
  • Fax: 719-274-6003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.0122450
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN.0122450
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: