Provider Demographics
NPI:1992047401
Name:BENNETT, SHANNON (ARNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BROWN-SCHAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:8875 SILVER ST
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-8542
Mailing Address - Country:US
Mailing Address - Phone:515-321-8245
Mailing Address - Fax:
Practice Address - Street 1:1325 SW ORALABOR RD STE 220
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-8046
Practice Address - Country:US
Practice Address - Phone:515-720-4377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2023-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-114718363L00000X
IAA114718363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1992047401Medicaid