Healthcare Provider Details

I. General information

NPI: 1639342173
Provider Name (Legal Business Name): SHAE A DORAN D.C., CACCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5583 W WATERFORD LN STE B
APPLETON WI
54913
US

IV. Provider business mailing address

5583 W WATERFORD LN STE B
APPLETON WI
54913
US

V. Phone/Fax

Practice location:
  • Phone: 920-419-1457
  • Fax: 920-243-0241
Mailing address:
  • Phone: 920-419-1457
  • Fax: 920-243-0241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number4205-012
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number4205-12
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4205-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: