Provider Demographics
NPI:1013291434
Name:SHANE, SUZANNE ELIZABETH (ACNP)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:SHANE
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:ELIZABETH
Other - Last Name:LANGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:913 E 26TH ST STE 305
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4515
Practice Address - Country:US
Practice Address - Phone:612-871-7278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP5086363LA2100X, 363L00000X
MNCNP 5086363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care