Basic Information
| Provider Information | |||||||||
| NPI: | 1881256378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILES | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | RAQUEL | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4545 N 36TH ST STE 126 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850183456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233290551 | ||||||||
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| Practice Location | |||||||||
| Address1: | 287 E HUNT HWY STE 105 | ||||||||
| Address2: | |||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851435096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806778282 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2019 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 165853 | AZ | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 363LP0808X | 235897 | AZ | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | 235897 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.