Healthcare Provider Details

I. General information

NPI: 1265901904
Provider Name (Legal Business Name): ANNA MICHELLE SHINNEMAN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2018
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

20 TEAL ST
PONTOON BEACH IL
62040-6480
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5631
  • Fax:
Mailing address:
  • Phone: 636-345-0254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number2018041867
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: