Provider Demographics
NPI:1841713450
Name:TANGEN, SHELLANE MARIE (BSN, MSN, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SHELLANE
Middle Name:MARIE
Last Name:TANGEN
Suffix:
Gender:F
Credentials:BSN, MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2183 WAGON TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:WHITE HEATH
Mailing Address - State:IL
Mailing Address - Zip Code:61884-9313
Mailing Address - Country:US
Mailing Address - Phone:217-621-6874
Mailing Address - Fax:
Practice Address - Street 1:819 BLOOMINGTON RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-2101
Practice Address - Country:US
Practice Address - Phone:217-356-1558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015253363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner