Provider Demographics
NPI:1760775142
Name:SNYDER, SHANNON LESLIE (RN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LESLIE
Last Name:SNYDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12567 5TH AVE N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398-8451
Mailing Address - Country:US
Mailing Address - Phone:763-856-9955
Mailing Address - Fax:763-856-9956
Practice Address - Street 1:12567 5TH AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:ZIMMERMAN
Practice Address - State:MN
Practice Address - Zip Code:55398-8451
Practice Address - Country:US
Practice Address - Phone:763-856-9955
Practice Address - Fax:763-856-9956
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-127118-4163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse