Provider Demographics
NPI:1336617398
Name:WILSON, SHANNON (RN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:RUPORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:880 GOLFVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ZUMBROTA
Mailing Address - State:MN
Mailing Address - Zip Code:55992-7336
Mailing Address - Country:US
Mailing Address - Phone:507-261-3200
Mailing Address - Fax:
Practice Address - Street 1:228 19TH ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-2327
Practice Address - Country:US
Practice Address - Phone:507-261-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR100005163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Single Specialty