Healthcare Provider Details

I. General information

NPI: 1851393649
Provider Name (Legal Business Name): SHANON L KJELSTAD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8990 SPRINGBROOK DR NW
COON RAPIDS MN
55433-5884
US

IV. Provider business mailing address

17241 PARTRIDGE ST NW
ANDOVER MN
55304-1453
US

V. Phone/Fax

Practice location:
  • Phone: 763-398-0099
  • Fax: 763-398-0124
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 125106-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: