Provider Demographics
NPI:1265891154
Name:BECKER, SHANNON (ARNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-6290
Mailing Address - Fax:515-222-7791
Practice Address - Street 1:1601 NW 114TH ST STE 242
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7036
Practice Address - Country:US
Practice Address - Phone:515-643-6290
Practice Address - Fax:515-222-7791
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG126878363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health