Provider Demographics
NPI:1093787616
Name:BACKSTROM, SHANNON LYNN (CNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:BACKSTROM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 86370
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6370
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:1417 S. CLIFF AVE.
Practice Address - Street 2:STE. 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1063
Practice Address - Country:US
Practice Address - Phone:605-322-8937
Practice Address - Fax:605-322-8938
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000442363LP1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD2387949OtherARAZ/ AMERICA'S PPO
MN400070600Medicaid
MN83G56BEOtherCC SYSTEMS/ BLUE PLUS
SD283761045259OtherPREFERRED ONE
SD9244760OtherDAKOTACARE
SDHP55697OtherHEALTHPARTNERS
SD0407827OtherMEDICA
IA0503706Medicaid
SD57105AD05OtherWPS TRICARE
SD6828300Medicaid
NE10025040700Medicaid
SD248007OtherBLUE CROSS
SD370624200OtherDEPT OF LABOR
SD6828302Medicaid
MN83G56BEOtherBLUE CROSS
MN924114229808OtherPRIMEWEST
SD248007OtherMIDLANDS CHOICE
MN83G56BEOtherBLUE CROSS
SD283761045259OtherPREFERRED ONE
MN400070600Medicaid