Healthcare Provider Details

I. General information

NPI: 1114382363
Provider Name (Legal Business Name): SHANNON M SICARD APRN, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 EAST MAIN ST
CROSBY MN
56441
US

IV. Provider business mailing address

320 EAST MAIN ST
CROSBY MN
56441
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-7000
  • Fax: 218-546-4400
Mailing address:
  • Phone: 218-546-7000
  • Fax: 218-546-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 190730-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: