Provider Demographics
NPI:1346614088
Name:SWANSON, SHANNON LEE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9615
Mailing Address - Country:US
Mailing Address - Phone:989-269-9521
Mailing Address - Fax:
Practice Address - Street 1:2750 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:MARLETTE
Practice Address - State:MI
Practice Address - Zip Code:48453
Practice Address - Country:US
Practice Address - Phone:989-635-4104
Practice Address - Fax:877-762-6751
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704254119363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner