Provider Demographics
NPI:1013347665
Name:WAGENMAN, SHANNON M (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:WAGENMAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:MCGINITY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:17 N MILES AVE
Mailing Address - Street 2:
Mailing Address - City:HARDIN
Mailing Address - State:MT
Mailing Address - Zip Code:59034-2323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 N MILES AVE
Practice Address - Street 2:
Practice Address - City:HARDIN
Practice Address - State:MT
Practice Address - Zip Code:59034-2323
Practice Address - Country:US
Practice Address - Phone:406-665-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-19
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT100410363LF0000X
MTNUR-RN-LIC-71603363LF0000X
CO0990549363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily