Provider Demographics
NPI:1063138162
Name:SHOTLIFF, KRYSTAL MARIE (FNP)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MARIE
Last Name:SHOTLIFF
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3270
Mailing Address - Country:US
Mailing Address - Phone:719-792-9192
Mailing Address - Fax:
Practice Address - Street 1:201 LAMKIN ST. UNIT 101
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-8100
Practice Address - Country:US
Practice Address - Phone:719-543-6633
Practice Address - Fax:719-543-6655
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0998109363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner