Provider Demographics
NPI:1023158458
Name:BICKNASE, SHANNA LORRAINE (ATC)
Entity type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:LORRAINE
Last Name:BICKNASE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4238 9TH AVE S APT 108
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2068
Mailing Address - Country:US
Mailing Address - Phone:605-201-6492
Mailing Address - Fax:
Practice Address - Street 1:1301 12TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3400
Practice Address - Country:US
Practice Address - Phone:701-231-8011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND308-06390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program