Provider Demographics
NPI:1891564910
Name:NISSEN, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NISSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-3702
Mailing Address - Country:US
Mailing Address - Phone:406-265-1229
Mailing Address - Fax:
Practice Address - Street 1:730 1ST ST
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-3702
Practice Address - Country:US
Practice Address - Phone:406-265-1229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT98044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist