Healthcare Provider Details

I. General information

NPI: 1033880802
Provider Name (Legal Business Name): SHAWNIE PERSONIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5362 KINGSTON PL NW
ROCHESTER MN
55901-2172
US

IV. Provider business mailing address

5362 KINGSTON PL NW
ROCHESTER MN
55901-2172
US

V. Phone/Fax

Practice location:
  • Phone: 707-296-0550
  • Fax:
Mailing address:
  • Phone: 707-296-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number138718
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: