Provider Demographics
NPI:1023770385
Name:SHANNON, GRACE A (NP)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:SHANNON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:CO
Mailing Address - Zip Code:80214-1256
Mailing Address - Country:US
Mailing Address - Phone:708-860-7091
Mailing Address - Fax:
Practice Address - Street 1:4545 E 9TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3906
Practice Address - Country:US
Practice Address - Phone:303-991-0993
Practice Address - Fax:303-531-6583
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONA363LF0000X
CO0997074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily