NPIMap

Individual provider Active NPI

Shannon Marie Roberts, FNP

  • Family Nurse Practitioner
  • Prescott, AZ
National Provider Identifier
1720854144
Registry record updated Feb 17, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
300448 Issued in AZ
Practice address
1050 Gail Gardner Way Ste 100
Prescott, AZ 86305-1631
Phone
(928) 777-0700
Fax
(928) 445-4464
NPI assigned
Nov 27, 2023
Last updated
Feb 17, 2025By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 17, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X 300448 AZ Primary

Addresses

Primary practice location

1050 Gail Gardner Way Ste 100
Prescott, AZ 86305-1631

Mailing address

PO Box 10880
Prescott, AZ 86304-0880
Phone (602) 406-4786

Other identifiers 1

IdentifierTypeStateIssuer
212822MedicaidAZ

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20240205002063 AZ Practitioner - Nurse Practitioner 6103269394 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

1050 Gail Gardner Way
Suite 300
Prescott, AZ 86305-1640
Phone (928) 717-5232

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
300448AZMDFamily Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Black Canyon Community Health Center, Inc. CurrentSince Feb 1, 2024 Accepting new patients
Yavapai Regional Medical Center Physician Care LLC Current Accepting new patients
Yavapai Regional Medical Center Physician Care LLC CurrentSince Oct 1, 2024 Accepting new patients
Black Canyon Community Health Center, Inc. Current Accepting new patients
Prescott Gastroenterology Past Accepting new patients

Locations

19251 E Oasis Dr
Black Cyn Cty, AZ 85324
Phone (602) 298-7777

1050 Gail Gardner Way
Ste 100
Prescott, AZ 86305
Phone (928) 443-9753

1050 Gail Gardner Way
Ste 300
Prescott, AZ 86305
Phone (928) 717-5232

3120 Clearwater Dr
Prescott, AZ 86305
Phone (928) 445-4818

17301 E Spring Valley Rd
Ste F
Spring Valley, AZ 86333
Phone (928) 632-4909

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/16465/brand/1/csg/1/fhir/r4

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1701043200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1739750400000",
    "number": "1720854144",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 10880",
            "city": "PRESCOTT",
            "state": "AZ",
            "postal_code": "863040880",
            "telephone_number": "602-406-4786",
            "fax_number": "916-636-4358"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1050 GAIL GARDNER WAY STE 100",
            "city": "PRESCOTT",
            "state": "AZ",
            "postal_code": "863051631",
            "telephone_number": "928-777-0700",
            "fax_number": "928-445-4464"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROBERTS",
        "first_name": "SHANNON",
        "middle_name": "MARIE",
        "name_prefix": "Mrs.",
        "credential": "FNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2023-11-27",
        "last_updated": "2025-02-17",
        "certification_date": "2025-02-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "AZ",
            "license": "300448",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "212822",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Prescott, AZ

Sources for this page

Verify at the official NPI Registry.