Provider Demographics
NPI:1710938899
Name:SHINE, CATHY DIANE (NP)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:DIANE
Last Name:SHINE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 W. AMERICAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2883
Mailing Address - Country:US
Mailing Address - Phone:920-725-9373
Mailing Address - Fax:920-720-7392
Practice Address - Street 1:1305 W. AMERICAN DRIVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2883
Practice Address - Country:US
Practice Address - Phone:920-725-9373
Practice Address - Fax:920-720-7392
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2005007423363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41278400Medicaid
WI005A71450OtherMEDICAID
WI005A71450OtherMEDICAID
WI41278400Medicaid