Basic Information
| Provider Information | |||||||||
| NPI: | 1336775717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHOWALD | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183335000 | ||||||||
| FaxNumber: | 2183335880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 ANNE ST NW | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566015114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183335000 | ||||||||
| FaxNumber: | 2183335880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2020 | ||||||||
| LastUpdateDate: | 07/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 7109 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.