Provider Demographics
NPI:1811535347
Name:LEININGER, SHANNON MARIE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:LEININGER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 N NOKOMIS ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-5118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:503 N NOKOMIS ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-5118
Practice Address - Country:US
Practice Address - Phone:320-762-0766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6572Medicaid