Healthcare Provider Details

I. General information

NPI: 1568943231
Provider Name (Legal Business Name): SHANON LEE MEKOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10176 W 400 N STE C
MICHIGAN CITY IN
46360-9009
US

IV. Provider business mailing address

10176 W 400 N STE C
MICHIGAN CITY IN
46360-9009
US

V. Phone/Fax

Practice location:
  • Phone: 219-873-1777
  • Fax: 219-873-0001
Mailing address:
  • Phone: 219-873-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71008506A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: