Provider Demographics
NPI:1982995627
Name:SHUN, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SHUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 PARK ST E
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302-3060
Practice Address - Country:US
Practice Address - Phone:320-274-3737
Practice Address - Fax:320-274-3631
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200463224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant