Healthcare Provider Details

I. General information

NPI: 1710296033
Provider Name (Legal Business Name): SHANNON CHRISTINE MATTHEWS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON MATTHEWS APRN

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 01/02/2024
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11824 MULLAN GULCH RD
SAINT REGIS MT
59866-9640
US

IV. Provider business mailing address

11824 MULLAN GULCH RD
SAINT REGIS MT
59866-9640
US

V. Phone/Fax

Practice location:
  • Phone: 702-338-2888
  • Fax:
Mailing address:
  • Phone: 702-338-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNUR-LIC-159478
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number527091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: