Provider Demographics
NPI:1033559802
Name:LAESCH, SHANNON L (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:LAESCH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 E WASHINGTON ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4365
Mailing Address - Country:US
Mailing Address - Phone:309-808-1450
Mailing Address - Fax:949-561-4829
Practice Address - Street 1:2103 E WASHINGTON ST STE 2C
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4365
Practice Address - Country:US
Practice Address - Phone:309-808-1450
Practice Address - Fax:949-561-4829
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010219364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health