Provider Demographics
NPI:1427010529
Name:TIMMERMAN, SHANNON RAE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RAE
Last Name:TIMMERMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6636 CEDAR AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2705
Mailing Address - Country:US
Mailing Address - Phone:612-467-5719
Mailing Address - Fax:
Practice Address - Street 1:6636 CEDAR AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2705
Practice Address - Country:US
Practice Address - Phone:612-467-5719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA104267363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0433078Medicaid
IA0433078Medicaid
Q06578Medicare UPIN