Healthcare Provider Details

I. General information

NPI: 1043137946
Provider Name (Legal Business Name): SHANNON ODEAN SAMSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18050 121ST AVE SW
DES LACS ND
58733-9418
US

IV. Provider business mailing address

18050 121ST AVE SW
DES LACS ND
58733-9418
US

V. Phone/Fax

Practice location:
  • Phone: 701-720-0695
  • Fax:
Mailing address:
  • Phone: 701-720-0695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: