=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912061466
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY J SHAFFER NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 04/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 722 S WAHSATCH AVE
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80903-4035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-632-5700
-----------------------------------------------------
Fax | 719-344-7828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3205 N ACADEMY BLVD SUITE 130
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80917-5101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-632-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 63257
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------