Provider Demographics
NPI:1215345210
Name:PETERSON, SHANNON (DNP, ARNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DNP, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-1936
Mailing Address - Country:US
Mailing Address - Phone:712-243-2850
Mailing Address - Fax:712-243-7423
Practice Address - Street 1:1501 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1936
Practice Address - Country:US
Practice Address - Phone:712-243-2850
Practice Address - Fax:712-243-7423
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA112768363LF0000X
IAH112768363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care