Healthcare Provider Details

I. General information

NPI: 1558728337
Provider Name (Legal Business Name): SHANNA JAY DIERKER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 N GATEWAY DR
APPLETON WI
54913-7863
US

IV. Provider business mailing address

3 NEENAH CTR
NEENAH WI
54956-3070
US

V. Phone/Fax

Practice location:
  • Phone: 920-702-6371
  • Fax:
Mailing address:
  • Phone: 920-702-6371
  • Fax: 920-358-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA143402
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-014331
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15817
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2015032867
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041404031
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: