Healthcare Provider Details

I. General information

NPI: 1013870559
Provider Name (Legal Business Name): LEILANA ROSE SHATTUCK
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: LOKI LUCIAN RENANDER

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 E 104TH PL UNIT 105
COMMERCE CITY CO
80022-2098
US

IV. Provider business mailing address

12303 E 104TH PL UNIT 105
COMMERCE CITY CO
80022-2098
US

V. Phone/Fax

Practice location:
  • Phone: 720-617-1574
  • Fax:
Mailing address:
  • Phone: 720-617-1574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: