Healthcare Provider Details

I. General information

NPI: 1003222597
Provider Name (Legal Business Name): SHANNON N SIEKAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13060 ISLE DR
BAXTER MN
56425-8331
US

IV. Provider business mailing address

523 N 3RD ST
BRAINERD MN
56401-3054
US

V. Phone/Fax

Practice location:
  • Phone: 218-828-2880
  • Fax:
Mailing address:
  • Phone: 218-828-2880
  • Fax: 218-454-5916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number179217-1
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: