Provider Demographics
NPI:1346754652
Name:VAN DE WEERD, SHELLY ANN (RN)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:VAN DE WEERD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2683
Mailing Address - Country:US
Mailing Address - Phone:715-551-0346
Mailing Address - Fax:
Practice Address - Street 1:916 S 10TH ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6502
Practice Address - Country:US
Practice Address - Phone:715-570-8912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI198871163W00000X
WI19877130163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse