Healthcare Provider Details

I. General information

NPI: 1134546260
Provider Name (Legal Business Name): SHANNON L JEFFERY DNP, AGPCNP-BC, PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-1415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209011386
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberCNP60684
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: