Provider Demographics
NPI:1902391626
Name:VELDKAMP, SHANNON KOENDERS (OD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KOENDERS
Last Name:VELDKAMP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19879 NAPLES ST NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-8859
Mailing Address - Country:US
Mailing Address - Phone:605-941-9628
Mailing Address - Fax:
Practice Address - Street 1:12771 RIVERDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-1262
Practice Address - Country:US
Practice Address - Phone:763-421-1220
Practice Address - Fax:763-421-1291
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3577152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy