Provider Demographics
NPI:1073831269
Name:NOLAN, SHANNON NICOLE BAILEY (MD)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:NICOLE BAILEY
Last Name:NOLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:NICOLE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3955 PARKLAWN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5655
Mailing Address - Country:US
Mailing Address - Phone:951-831-2388
Mailing Address - Fax:
Practice Address - Street 1:3955 PARKLAWN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5655
Practice Address - Country:US
Practice Address - Phone:951-831-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN56209208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program