Provider Demographics
NPI:1558432773
Name:BAKER, SHANNON LEE (MSN, ACNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:BAKER
Suffix:
Gender:F
Credentials:MSN, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 PIPER STREET SUITE A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-222-4624
Mailing Address - Fax:907-222-4651
Practice Address - Street 1:3200 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-261-3641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK877363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP5538Medicaid
AK160399Medicare ID - Type Unspecified
AKQ15579Medicare UPIN