Provider Demographics
NPI:1457321614
Name:SHANNON, SHERYL P (APRN)
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:P
Last Name:SHANNON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7710 MERCY RD
Mailing Address - Street 2:SUITE 122
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2372
Mailing Address - Country:US
Mailing Address - Phone:402-393-3110
Mailing Address - Fax:402-393-4499
Practice Address - Street 1:7710 MERCY RD
Practice Address - Street 2:SUITE 122
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2372
Practice Address - Country:US
Practice Address - Phone:402-393-3110
Practice Address - Fax:402-393-4499
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110372363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
274716Medicare ID - Type Unspecified
P11740Medicare UPIN