Provider Demographics
NPI:1184263253
Name:NIGHTSHADE, CARRIE SHANNON (LAC, MAC, DIPLAC)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:SHANNON
Last Name:NIGHTSHADE
Suffix:
Gender:F
Credentials:LAC, MAC, DIPLAC
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:SHANNON
Other - Last Name:FELSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3706 E 42ND STREET, MINNEAPOLIS COMMUNITY ACUPUNCTURE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406
Mailing Address - Country:US
Mailing Address - Phone:612-708-8917
Mailing Address - Fax:
Practice Address - Street 1:3706 E 42ND STREET
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406
Practice Address - Country:US
Practice Address - Phone:612-708-8917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1565171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist