Provider Demographics
NPI:1790750677
Name:SHANNON, MARCIA ANN (FNP C)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:ANN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:FNP C
Other - Prefix:MISS
Other - First Name:MARCIA
Other - Middle Name:ANN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:40520 COUNTY HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:MN
Mailing Address - Zip Code:56569-9612
Mailing Address - Country:US
Mailing Address - Phone:218-983-4300
Mailing Address - Fax:218-983-6360
Practice Address - Street 1:40520 COUNTY HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569-9612
Practice Address - Country:US
Practice Address - Phone:218-983-4300
Practice Address - Fax:218-983-6360
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN24590363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8HL323OtherMEDICARE PTAN