Provider Demographics
NPI:1316417637
Name:MEDDAUGH, SHANNON JANELL
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JANELL
Last Name:MEDDAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9582 COUNTY HIGHWAY BB
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-9074
Mailing Address - Country:US
Mailing Address - Phone:612-859-6472
Mailing Address - Fax:
Practice Address - Street 1:1000 OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-5444
Practice Address - Country:US
Practice Address - Phone:800-782-8581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8854363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner