Provider Demographics
NPI:1376882647
Name:WITGES, SHANNA (APRN NP-C)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:WITGES
Suffix:
Gender:F
Credentials:APRN NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 HAMACHER ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1592
Mailing Address - Country:US
Mailing Address - Phone:618-939-3939
Mailing Address - Fax:618-939-3941
Practice Address - Street 1:509 HAMACHER ST STE 102
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013002942363LF0000X
IL277000985363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily