Healthcare Provider Details

I. General information

NPI: 1841714292
Provider Name (Legal Business Name): SHANNON GOINS-BLAIR CLT-LANA, AFMC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 MONTGOMERY BLVD NE STE G
ALBUQUERQUE NM
87109-1425
US

IV. Provider business mailing address

20 CAMINO YRISARRI
TIJERAS NM
87059-6300
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-1855
  • Fax:
Mailing address:
  • Phone: 505-554-5185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8941
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberCLT
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberFUNCTIONALMEDICINE
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: