Healthcare Provider Details

I. General information

NPI: 1386428811
Provider Name (Legal Business Name): SHANNON LANE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 N BALLARD RD
APPLETON WI
54911-8701
US

IV. Provider business mailing address

108 LAMINE LN
COMBINED LOCKS WI
54113-1100
US

V. Phone/Fax

Practice location:
  • Phone: 920-512-8822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number13535-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: