Provider Demographics
NPI:1598081440
Name:NIERMAN, SHANNON LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEE
Last Name:NIERMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 SHAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1443
Mailing Address - Country:US
Mailing Address - Phone:260-797-2146
Mailing Address - Fax:
Practice Address - Street 1:6320 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1518
Practice Address - Country:US
Practice Address - Phone:260-432-7339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-18
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002640A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400039543Medicare UPIN