Provider Demographics
NPI:1265493209
Name:KEIDEL, SHANNON LEE (RN)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEE
Last Name:KEIDEL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:LEE
Other - Last Name:SCHUETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7420 E WIND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-1512
Mailing Address - Country:US
Mailing Address - Phone:262-895-2692
Mailing Address - Fax:
Practice Address - Street 1:7420 E WIND LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-1512
Practice Address - Country:US
Practice Address - Phone:262-895-2692
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39862100Medicaid