Provider Demographics
NPI:1518306414
Name:GODSIL, SHANNON KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:GODSIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:HARDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1343 S 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-2425
Mailing Address - Country:US
Mailing Address - Phone:708-846-7684
Mailing Address - Fax:
Practice Address - Street 1:9801 GILES RD STE 1
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-2925
Practice Address - Country:US
Practice Address - Phone:402-955-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NETEP#6973208000000X
NE29266208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics