=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558455725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. SHANNAN LEE ANDERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 VETERANS DR
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55417-2309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-467-3853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2352 BARCLAY ST
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-2056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2865M2000X
-----------------------------------------------------
Taxonomy Name | Military General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------