Basic Information
| Provider Information | |||||||||
| NPI: | 1164742342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANGREAUX | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | EAST HIGWAY 18 | ||||||||
| Address2: | |||||||||
| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058675131 | ||||||||
| FaxNumber: | 6058673332 | ||||||||
| Practice Location | |||||||||
| Address1: | EAST HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058675131 | ||||||||
| FaxNumber: | 6058673332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2010 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R034803 | SD | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | R034803 | 05 | SD | MEDICAID |