Provider Demographics
NPI:1326066275
Name:KITTLESON, SHANNON (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KITTLESON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4508
Mailing Address - Country:US
Mailing Address - Phone:701-530-8800
Mailing Address - Fax:701-530-8763
Practice Address - Street 1:310 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4508
Practice Address - Country:US
Practice Address - Phone:701-530-8800
Practice Address - Fax:701-530-8763
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR24358363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19662Medicaid
ND14785Medicare UPIN
ND20720Medicare ID - Type UnspecifiedND MEDICARE
ND19662Medicaid