Healthcare Provider Details

I. General information

NPI: 1982291209
Provider Name (Legal Business Name): SHANNON ALICE LADD CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 W 23RD ST STE 130
ST LOUIS PARK MN
55416-1670
US

IV. Provider business mailing address

5320 W 23RD ST STE 130
ST LOUIS PARK MN
55416-1670
US

V. Phone/Fax

Practice location:
  • Phone: 952-345-3310
  • Fax: 952-345-8771
Mailing address:
  • Phone: 952-345-3310
  • Fax: 952-345-8771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14756
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: