Provider Demographics
NPI:1588464697
Name:DANIELS, SHANNON BROOKE (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:BROOKE
Last Name:DANIELS
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N BARKLEY
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-8933
Mailing Address - Country:US
Mailing Address - Phone:602-930-5648
Mailing Address - Fax:
Practice Address - Street 1:6750 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1700
Practice Address - Country:US
Practice Address - Phone:480-756-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ321242363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology