Healthcare Provider Details

I. General information

NPI: 1629670096
Provider Name (Legal Business Name): SHANA LIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

978 EUCLID AVE
CARBONDALE CO
81623-1820
US

IV. Provider business mailing address

1906 BLAKE AVE
GLENWOOD SPRINGS CO
81601-4259
US

V. Phone/Fax

Practice location:
  • Phone: 970-963-3350
  • Fax: 970-963-2958
Mailing address:
  • Phone: 970-384-7033
  • Fax: 970-384-8174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0995947-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: