Provider Demographics
NPI:1942397476
Name:DANTONIO, SHANNON S (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:S
Last Name:DANTONIO
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 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-330-3688
Mailing Address - Fax:812-355-3270
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-330-3688
Practice Address - Fax:812-355-3270
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000249A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201273190Medicaid
IN201273190Medicaid