Healthcare Provider Details

I. General information

NPI: 1760267074
Provider Name (Legal Business Name): SHANNON PAUL LITTLEWOLF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON PAUL LITTLEWOLF

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 13TH AVE SE APT 40
DEVILS LAKE ND
58301-3250
US

IV. Provider business mailing address

18 PITCHER PARK SE
DEVILS LAKE ND
58301-3909
US

V. Phone/Fax

Practice location:
  • Phone: 701-381-8647
  • Fax:
Mailing address:
  • Phone: 701-381-8647
  • 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: