Healthcare Provider Details

I. General information

NPI: 1598081440
Provider Name (Legal Business Name): SHANNON LEE NIERMAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2010
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 CONSTITUTION DR
FORT WAYNE IN
46804-1518
US

IV. Provider business mailing address

3007 SHAWNEE DR
FORT WAYNE IN
46807-1443
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-7339
  • Fax:
Mailing address:
  • Phone: 260-797-2146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08002640A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: