Basic Information
| Provider Information | |||||||||
| NPI: | 1326066275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KITTLESON | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015308800 | ||||||||
| FaxNumber: | 7015308763 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015308800 | ||||||||
| FaxNumber: | 7015308763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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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 | 363L00000X | R24358 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 19662 | 05 | ND | MEDICAID |