Provider Demographics
NPI:1952467441
Name:NUNLIST, SHANNON (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:NUNLIST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51657 US HIGHWAY 93
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-6903
Mailing Address - Country:US
Mailing Address - Phone:406-883-6863
Mailing Address - Fax:406-883-6868
Practice Address - Street 1:51657 US HIGHWAY 93
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-6903
Practice Address - Country:US
Practice Address - Phone:406-883-6863
Practice Address - Fax:406-883-6868
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT641PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000061551OtherBLUE CROSS OF MONTANA
MTP00434173OtherRAILROAD MEDICARE
MT3402091Medicaid
MT020765623OtherEIN
MT000061551OtherBLUE CROSS OF MONTANA