Provider Demographics
NPI:1932695178
Name:PIERSON, SHAE LEANN (RN, PHN)
Entity Type:Individual
Prefix:
First Name:SHAE
Middle Name:LEANN
Last Name:PIERSON
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:SHAE
Other - Middle Name:LEANN
Other - Last Name:FREDRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, PHN
Mailing Address - Street 1:117 W BLUE EARTH AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-1724
Mailing Address - Country:US
Mailing Address - Phone:507-235-3898
Mailing Address - Fax:507-238-5488
Practice Address - Street 1:117 W BLUE EARTH AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-1724
Practice Address - Country:US
Practice Address - Phone:507-235-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26681163WC1500X
MN2429090163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health