Provider Demographics
NPI:1558779058
Name:HOLTHAUS, SHANNON MARIE (APN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:HOLTHAUS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:HAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4459
Practice Address - Street 1:1802 S MATTIS AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5923
Practice Address - Country:US
Practice Address - Phone:217-383-3260
Practice Address - Fax:217-383-4459
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.011667363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily