Provider Demographics
NPI:1083639728
Name:FOSSO, SHELDA SUE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHELDA
Middle Name:SUE
Last Name:FOSSO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MS
Other - First Name:SHELDA
Other - Middle Name:SUE
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:155 N SAWYER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-5674
Mailing Address - Country:US
Mailing Address - Phone:920-230-7600
Mailing Address - Fax:920-230-7603
Practice Address - Street 1:155 N SAWYER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-5674
Practice Address - Country:US
Practice Address - Phone:920-230-7600
Practice Address - Fax:920-230-7603
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3365-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38896900Medicaid
WI38896900Medicaid
WI704200006Medicare ID - Type Unspecified