Healthcare Provider Details

I. General information

NPI: 1912505090
Provider Name (Legal Business Name): SHAWNA MARIE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 06/23/2024
Certification Date: 06/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9732 HIGHWAY 30
ROLLA ND
58367-9528
US

IV. Provider business mailing address

PO BOX 1
ROLLA ND
58367-0001
US

V. Phone/Fax

Practice location:
  • Phone: 701-550-0387
  • Fax:
Mailing address:
  • Phone: 701-550-0387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: