Provider Demographics
NPI:1215520085
Name:CHAN, SHANNON MARIE (FNP-C)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:CHAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:5521 VENTANA DEL SOL DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3453
Mailing Address - Country:US
Mailing Address - Phone:917-318-9518
Mailing Address - Fax:
Practice Address - Street 1:5521 VENTANA DEL SOL DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3453
Practice Address - Country:US
Practice Address - Phone:917-318-9518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141616363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily