Provider Demographics
NPI:1659409563
Name:BEASLEY, SHANNON M (CPNP, PHN, CDE)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:CPNP, PHN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 DELAWARE ST. SE
Mailing Address - Street 2:PWB ROOM 7-111, MMC 504
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-5609
Mailing Address - Fax:612-626-5206
Practice Address - Street 1:516 DELAWARE ST. SE
Practice Address - Street 2:PWB ROOM 7-111, MMC 504
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-5609
Practice Address - Fax:612-626-5206
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3938363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics