Provider Demographics
NPI:1174801138
Name:BLACKSTOCK, SHANNON (RN, CPNP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:BLACKSTOCK
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BARBARA JORDAN BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 BARBARA JORDAN BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3077
Practice Address - Country:US
Practice Address - Phone:512-628-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX731190363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics