Healthcare Provider Details

I. General information

NPI: 1104459908
Provider Name (Legal Business Name): SONIA SIMEONI-SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 07/31/2023
Certification Date: 07/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 CUESTA RD
SANTA FE NM
87508-8780
US

IV. Provider business mailing address

34 CUESTA RD
SANTA FE NM
87508-8780
US

V. Phone/Fax

Practice location:
  • Phone: 607-215-2807
  • Fax:
Mailing address:
  • Phone: 607-215-2807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number60073
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: