Provider Demographics
NPI:1336219328
Name:WESLEY, SHANNON JEAN (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JEAN
Last Name:WESLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 E OWATONNA ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-1804
Mailing Address - Country:US
Mailing Address - Phone:218-724-2123
Mailing Address - Fax:
Practice Address - Street 1:512 SKYLINE BLVD
Practice Address - Street 2:COMMUNITY MEMORIAL HOSPITAL
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine