Provider Demographics
NPI:1720854144
Name:ROBERTS, SHANNON MARIE (FNP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:ROBERTS
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:1050 GAIL GARDNER WAY STE 100
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1631
Practice Address - Country:US
Practice Address - Phone:928-777-0700
Practice Address - Fax:928-445-4464
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ300448363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ212822Medicaid