Healthcare Provider Details

I. General information

NPI: 1881001899
Provider Name (Legal Business Name): SHANNON BRASLAVSKY AGPNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date: 01/07/2025
Reactivation Date: 01/17/2025

III. Provider practice location address

3555 STONE CREEK CIR SW
CEDAR RAPIDS IA
52404-1240
US

IV. Provider business mailing address

430 B AVE NE
WALFORD IA
52351-8018
US

V. Phone/Fax

Practice location:
  • Phone: 319-693-8800
  • Fax: 319-208-2273
Mailing address:
  • Phone: 501-943-9070
  • Fax: 319-208-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA004140
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA004140
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberA004140
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: