Healthcare Provider Details

I. General information

NPI: 1780727537
Provider Name (Legal Business Name): SHANNON B. TUCKWIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 MASSACHUSETTS ST
LAWRENCE KS
66046-4827
US

IV. Provider business mailing address

3209 W 29TH TER
LAWRENCE KS
66047-3912
US

V. Phone/Fax

Practice location:
  • Phone: 785-843-3750
  • Fax:
Mailing address:
  • Phone: 785-842-4143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number13-73091-072
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: