Healthcare Provider Details

I. General information

NPI: 1013347665
Provider Name (Legal Business Name): SHANNON M WAGENMAN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON M MCGINITY FNP

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 N MILES AVE
HARDIN MT
59034-2323
US

IV. Provider business mailing address

17 N MILES AVE
HARDIN MT
59034-2323
US

V. Phone/Fax

Practice location:
  • Phone: 406-665-2310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number100410
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNUR-RN-LIC-71603
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0990549
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: