Healthcare Provider Details

I. General information

NPI: 1831819242
Provider Name (Legal Business Name): SHANNON SCHROEDER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 08/06/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WISCONSIN AMERICAN DR
FOND DU LAC WI
54937-2999
US

IV. Provider business mailing address

516 VALLEY ST.
HORICON WI
53032
US

V. Phone/Fax

Practice location:
  • Phone: 920-907-7270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number15775-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: