Healthcare Provider Details

I. General information

NPI: 1841713450
Provider Name (Legal Business Name): SHELLANE MARIE TANGEN BSN, MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

IV. Provider business mailing address

2183 WAGON TRAIL RD
WHITE HEATH IL
61884-9313
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-1558
  • Fax:
Mailing address:
  • Phone: 217-621-6874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209015253
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: