Provider Demographics
NPI:1922531656
Name:ANDERSON, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E22105 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:CADOTT
Mailing Address - State:WI
Mailing Address - Zip Code:54727-9200
Mailing Address - Country:US
Mailing Address - Phone:715-667-5383
Mailing Address - Fax:
Practice Address - Street 1:3440 OAKWOOD HILLS PKWY
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7698
Practice Address - Country:US
Practice Address - Phone:715-214-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30254331164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse