Healthcare Provider Details

I. General information

NPI: 1679444921
Provider Name (Legal Business Name): SHALAH SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHALAH CUMMINGS

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 10/24/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

IV. Provider business mailing address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

V. Phone/Fax

Practice location:
  • Phone: 402-930-7099
  • Fax: 402-930-7982
Mailing address:
  • Phone: 402-930-7099
  • Fax: 402-930-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number85720
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: