Provider Demographics
NPI:1063542884
Name:STAFFORD, SHANNON RANAE (ARNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RANAE
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 THALLAS ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-8600
Mailing Address - Country:US
Mailing Address - Phone:712-325-9977
Mailing Address - Fax:
Practice Address - Street 1:1604 2ND AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3801
Practice Address - Country:US
Practice Address - Phone:712-322-6650
Practice Address - Fax:712-328-7985
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAF-091658363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0131656Medicaid
IAP80438Medicare UPIN
IA0131656Medicaid