Provider Demographics
NPI:1760267074
Name:LITTLEWOLF, SHANNON PAUL
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:PAUL
Last Name:LITTLEWOLF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:PAUL
Other - Last Name:LITTLEWOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 PITCHER PARK SE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-3909
Mailing Address - Country:US
Mailing Address - Phone:701-381-8647
Mailing Address - Fax:
Practice Address - Street 1:310 13TH AVE SE APT 40
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-3250
Practice Address - Country:US
Practice Address - Phone:701-381-8647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant