Provider Demographics
NPI:1225617103
Name:VANDERKOOI, SHANNON (DO)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:VANDERKOOI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:VANDER BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1115 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1013
Mailing Address - Country:US
Mailing Address - Phone:712-578-9539
Mailing Address - Fax:
Practice Address - Street 1:1115 E 20TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1013
Practice Address - Country:US
Practice Address - Phone:605-575-1644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program