Provider Demographics
NPI:1043568934
Name:DAVISON-WIESE, SHANNON ELIZABETH (ARNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:DAVISON-WIESE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ELIZABETH
Other - Last Name:DAVISON-HAIGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:1500 ASSOCIATES DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2201
Practice Address - Country:US
Practice Address - Phone:563-584-4460
Practice Address - Fax:563-584-4395
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA114726363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA016990067OtherMEDICARE PTAN