Provider Demographics
NPI:1326248360
Name:CLEMMONS, SHIRLEY LOUISE (BC-HIS)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:LOUISE
Last Name:CLEMMONS
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 E WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3969
Mailing Address - Country:US
Mailing Address - Phone:920-733-7525
Mailing Address - Fax:
Practice Address - Street 1:1336 E WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3969
Practice Address - Country:US
Practice Address - Phone:920-733-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI424237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI424OtherWI STATE LICENSE
WI42823200Medicaid