Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 HIGHWAY 50
PECOS NM
87552
US

IV. Provider business mailing address

199 HIGHWAY 50
PECOS NM
87552
US

V. Phone/Fax

Practice location:
  • Phone: 505-757-6482
  • Fax: 505-443-8304
Mailing address:
  • Phone: 505-757-6482
  • Fax: 505-443-8304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number86686
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: