MEDICARE: MS. SHAWNA PHILLIPS FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	1625862	CO
2	363LF0000X	Family Nurse Practitioner	APN.0995904-NP	CO

General Provider Information

NPI Number	:	1700296001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHAWNA PHILLIPS FNP

Provider Business Mailing Address
First Line	:	275 S MAIN ST STE 208
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80501-6461
Country	:	US
Telephone Number	:	720-224-1373
Fax Number	:

Provider Business Practice Location Address
First Line	:	275 S MAIN ST STE 208
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80501-6461
Country	:	US
Telephone Number	:	720-224-1373
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2014
Last Update Date	:	12/10/2020

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