Provider Demographics
NPI:1124307186
Name:JARAMILLO, SHANNON KAY (FNP-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAY
Last Name:JARAMILLO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 N STATE ROUTE 89
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-5643
Mailing Address - Country:US
Mailing Address - Phone:928-404-1488
Mailing Address - Fax:
Practice Address - Street 1:1934 N STATE ROUTE 89
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-5649
Practice Address - Country:US
Practice Address - Phone:928-404-1488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4015363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ91357Medicare PIN