Healthcare Provider Details

I. General information

NPI: 1043558331
Provider Name (Legal Business Name): SHANNON KING ADN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2013
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 GUADALUPE TRL NW
LOS RANCHOS NM
87114-1121
US

IV. Provider business mailing address

7500 TARGET LN NW
ALBUQUERQUE NM
87120-3065
US

V. Phone/Fax

Practice location:
  • Phone: 505-898-3666
  • Fax:
Mailing address:
  • Phone: 505-550-7303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR52018
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberR52018
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: