Provider Demographics
NPI:1841502788
Name:ROLF, SHANNON DAWN
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:DAWN
Last Name:ROLF
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:DAWN
Other - Last Name:FROST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2039 153RD AVE
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-7457
Mailing Address - Country:US
Mailing Address - Phone:320-679-5272
Mailing Address - Fax:
Practice Address - Street 1:2039 153RD AVE
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-7457
Practice Address - Country:US
Practice Address - Phone:320-679-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1057883-1-AFC253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency