Healthcare Provider Details

I. General information

NPI: 1164970588
Provider Name (Legal Business Name): SHANNON GWASH M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12055 W 2ND PL
LAKEWOOD CO
80228-1506
US

IV. Provider business mailing address

12055 WEST 2ND PLACE
LAKEWOOD CO
80228
US

V. Phone/Fax

Practice location:
  • Phone: 303-432-5659
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: