Healthcare Provider Details

I. General information

NPI: 1295656510
Provider Name (Legal Business Name): SHANNON RISING NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 COUNTY ROAD E E
WHITE BEAR LAKE MN
55110-4963
US

IV. Provider business mailing address

5170 FAIRPOINT DR N
HUGO MN
55038-7800
US

V. Phone/Fax

Practice location:
  • Phone: 651-777-6816
  • Fax:
Mailing address:
  • Phone: 612-802-8006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12061
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: