Provider Demographics
NPI:1104029388
Name:NELSON, SHANNON CARL (OTR)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:CARL
Last Name:NELSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621-0299
Mailing Address - Country:US
Mailing Address - Phone:218-679-3316
Mailing Address - Fax:218-679-3990
Practice Address - Street 1:HIGHWAY 1 BOX 497
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102239282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN102239OtherOCCUPATIONAL THERAPY LIC.