Provider Demographics
NPI:1558728337
Name:DIERKER, SHANNA JAY (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:JAY
Last Name:DIERKER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2719
Mailing Address - Country:US
Mailing Address - Phone:217-224-6423
Mailing Address - Fax:217-221-1344
Practice Address - Street 1:927 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2719
Practice Address - Country:US
Practice Address - Phone:217-224-6423
Practice Address - Fax:217-221-1344
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041404031163W00000X
MO2015032867163W00000X
IAA143402363LF0000X
IL209-014331363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse