Healthcare Provider Details

I. General information

NPI: 1215706296
Provider Name (Legal Business Name): SHANNON BEDORE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2024
Last Update Date: 06/28/2025
Certification Date: 06/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 ELK AVE STE 25
CRESTED BUTTE CO
81224-5450
US

IV. Provider business mailing address

PO BOX 2761
CRESTED BUTTE CO
81224-2761
US

V. Phone/Fax

Practice location:
  • Phone: 916-955-1147
  • Fax:
Mailing address:
  • Phone: 916-955-1147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number267519
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number267519
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberC-RXN.0101238-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: