Provider Demographics
NPI:1891779567
Name:KELLY-SCHUG, SHANNON M (GNP)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:M
Last Name:KELLY-SCHUG
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3850 PARK NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3850 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-5041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR120875-9363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
S33632Medicare UPIN