Healthcare Provider Details

I. General information

NPI: 1255203394
Provider Name (Legal Business Name): SHANNON AGNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES ST
FAIRBANKS AK
99701-5907
US

IV. Provider business mailing address

1650 COWLES ST
FAIRBANKS AK
99701-5907
US

V. Phone/Fax

Practice location:
  • Phone: 907-452-8181
  • Fax:
Mailing address:
  • Phone: 907-458-5684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number38983
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNURR38983
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: