Provider Demographics
NPI:1588621304
Name:HERMES, SHEA M (NNP)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:M
Last Name:HERMES
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4119
Mailing Address - Country:US
Mailing Address - Phone:651-225-8350
Mailing Address - Fax:
Practice Address - Street 1:720 STEWART AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-4119
Practice Address - Country:US
Practice Address - Phone:651-225-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1183311363L00000X
AZRN 079301363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN512455700Medicaid
MN512455700Medicaid