Healthcare Provider Details

I. General information

NPI: 1538925300
Provider Name (Legal Business Name): SHYANN ERICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2296 WOODALE DR
SAINT PAUL MN
55112-4900
US

IV. Provider business mailing address

668 207TH AVE
SOMERSET WI
54025-7249
US

V. Phone/Fax

Practice location:
  • Phone: 651-222-0555
  • Fax:
Mailing address:
  • Phone: 715-690-4799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number1023728
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: