Healthcare Provider Details

I. General information

NPI: 1477911071
Provider Name (Legal Business Name): SHANNON LEE PLOS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S VAN BUREN ST
GREEN BAY WI
54301-3526
US

IV. Provider business mailing address

2793 LINEVILLE RD
GREEN BAY WI
54313-7152
US

V. Phone/Fax

Practice location:
  • Phone: 920-884-5460
  • Fax: 920-884-5475
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number143070-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6799-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: