=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538925300
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHYANN ERICKSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2024
-----------------------------------------------------
Last Update Date | 02/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2296 WOODALE DR
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55112-4900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-222-0555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 668 207TH AVE
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54025-7249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-690-4799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 146N00000X
-----------------------------------------------------
Taxonomy Name | Basic Emergency Medical Technician
-----------------------------------------------------
License Number | 1023728
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------