Provider Demographics
NPI:1104919695
Name:MORTENSEN, SHANNON KAY (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAY
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KAY
Other - Last Name:ARMSTRONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2288 MERRITT CREEK LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-665-7546
Mailing Address - Fax:208-667-4607
Practice Address - Street 1:2288 MERRITT CREEK LOOP
Practice Address - Street 2:
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-665-7546
Practice Address - Fax:208-667-4607
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-31561363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806523200Medicaid
ID806523200Medicaid
ID1344091Medicare ID - Type Unspecified