Provider Demographics
NPI:1003393000
Name:NELSON, SHAUNA R (OTR/L, CLT)
Entity Type:Individual
Prefix:MRS
First Name:SHAUNA
Middle Name:R
Last Name:NELSON
Suffix:
Gender:F
Credentials:OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 31ST AVE S STE 104
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4557
Mailing Address - Country:US
Mailing Address - Phone:017-451-9417
Mailing Address - Fax:
Practice Address - Street 1:1711 GOLD DR S STE 120
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6416
Practice Address - Country:US
Practice Address - Phone:701-451-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND453225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND3482838934Medicaid