Healthcare Provider Details

I. General information

NPI: 1326994559
Provider Name (Legal Business Name): SHANNON WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 PORTWEST CT
SAINT CHARLES MO
63303-5985
US

IV. Provider business mailing address

1617 GRAPE AVE
SAINT LOUIS MO
63147-1405
US

V. Phone/Fax

Practice location:
  • Phone: 636-410-8292
  • Fax:
Mailing address:
  • Phone: 314-280-6366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2087
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number2087
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: