Provider Demographics
NPI:1265994362
Name:CLAY, SHANNON LEA (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEA
Last Name:CLAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELEWARE ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-626-9691
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-626-9691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
390200000X
MN35594390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program