Healthcare Provider Details

I. General information

NPI: 1780077255
Provider Name (Legal Business Name): SHANNEL MATTHEWS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

15430 S 183RD LN
GOODYEAR AZ
85338-3653
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9612
  • Fax:
Mailing address:
  • Phone: 915-309-3968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95013479
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number71787
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number71203
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: