Provider Demographics
NPI:1336775717
Name:MAHOWALD, SHELLY MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:MAHOWALD
Suffix:
Gender:F
Credentials:FNP-C
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:218-333-5000
Mailing Address - Fax:218-333-5880
Practice Address - Street 1:1611 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5114
Practice Address - Country:US
Practice Address - Phone:218-333-5000
Practice Address - Fax:218-333-5880
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty