Healthcare Provider Details

I. General information

NPI: 1780427518
Provider Name (Legal Business Name): SHANNON J VASQUEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 CALLEJON LAS ANIMAS
GLORIETA NM
87535-7040
US

IV. Provider business mailing address

6 CALLEJON LAS ANIMAS
GLORIETA NM
87535-7040
US

V. Phone/Fax

Practice location:
  • Phone: 505-819-9002
  • Fax:
Mailing address:
  • Phone: 505-819-9002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN-80565
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: