Provider Demographics
NPI:1205202074
Name:VANZUMMEREN, SHANNON (APN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:VANZUMMEREN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4028
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61204-4028
Mailing Address - Country:US
Mailing Address - Phone:563-355-9200
Mailing Address - Fax:563-355-3419
Practice Address - Street 1:855 ILLINI DR
Practice Address - Street 2:SUITE 304
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-2907
Practice Address - Country:US
Practice Address - Phone:309-281-2120
Practice Address - Fax:309-281-2129
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.013114363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily