Healthcare Provider Details

I. General information

NPI: 1821216417
Provider Name (Legal Business Name): SHANNON ELAINE WILSON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 N 7TH ST
SPRINGFIELD IL
62701-1014
US

IV. Provider business mailing address

401 AINTREE CHASE
SHERMAN IL
62684-9519
US

V. Phone/Fax

Practice location:
  • Phone: 217-544-6464
  • Fax: 217-522-1206
Mailing address:
  • Phone: 217-899-0807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: