Provider Demographics
NPI:1073056909
Name:WALOWSKI, SHANNON (MSN, APNP, AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WALOWSKI
Suffix:
Gender:F
Credentials:MSN, APNP, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 N 109TH ST
Mailing Address - Street 2:STE 1
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3754
Mailing Address - Country:US
Mailing Address - Phone:414-777-1811
Mailing Address - Fax:414-777-1812
Practice Address - Street 1:830 N 109TH ST STE 1
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3754
Practice Address - Country:US
Practice Address - Phone:414-777-1811
Practice Address - Fax:414-777-1812
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7131-33363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology