Provider Demographics
NPI:1609692920
Name:BRYN, SHANNON MARIE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:BRYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11148 16TH ST SE
Mailing Address - Street 2:
Mailing Address - City:DAZEY
Mailing Address - State:ND
Mailing Address - Zip Code:58429-9737
Mailing Address - Country:US
Mailing Address - Phone:701-840-9531
Mailing Address - Fax:
Practice Address - Street 1:7500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-9634
Practice Address - Country:US
Practice Address - Phone:701-355-8030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer