Provider Demographics
NPI:1881139426
Name:DEKKER, SHAMIAH M (CRNA)
Entity type:Individual
Prefix:
First Name:SHAMIAH
Middle Name:M
Last Name:DEKKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHAMIAH
Other - Middle Name:M
Other - Last Name:REID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:620 W BROWN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1702
Practice Address - Country:US
Practice Address - Phone:920-324-5581
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7440-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered