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General NPI Number Information
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NPI Number | 1881764876
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Entity Type | Individual
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Provider Name | SHANNON MARIE RISTAU
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Gender | Female
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2115 SUMMIT AVE LORAS HALL 406
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City | SAINT PAUL
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State | MN
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Zip | 55105-1048
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Country | US
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Telephone | 503-396-2896
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Fax |
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Provider Business Mailing Address
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Address Line | 1776 SAINT CLAIR AVE APT #407
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City | SAINT PAUL
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State | MN
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Zip | 55105-1962
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Country | US
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Telephone | 651-690-0177
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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