Provider Demographics
NPI:1144913914
Name:FANNING, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FANNING
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 1:309 E 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:TYNDALL
Mailing Address - State:SD
Mailing Address - Zip Code:57066-2228
Mailing Address - Country:US
Mailing Address - Phone:605-933-1681
Mailing Address - Fax:
Practice Address - Street 1:309 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:TYNDALL
Practice Address - State:SD
Practice Address - Zip Code:57066-2228
Practice Address - Country:US
Practice Address - Phone:605-933-1681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant