Provider Demographics
NPI:1780414060
Name:GAINES, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GAINES
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 1:23323 87TH ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:53168-9437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23323 87TH ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WI
Practice Address - Zip Code:53168-9437
Practice Address - Country:US
Practice Address - Phone:262-977-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.527344163WW0000X
WI234239-30163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care