Healthcare Provider Details

I. General information

NPI: 1891681599
Provider Name (Legal Business Name): SHANNON PITVOREC ATC, LAT, CEAS II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON NICKELS ATC, LAT

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9513 CLAREMONT AVE NE
ALBUQUERQUE NM
87112-1341
US

IV. Provider business mailing address

9513 CLAREMONT AVE NE
ALBUQUERQUE NM
87112-1341
US

V. Phone/Fax

Practice location:
  • Phone: 904-327-5005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT681
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: