Healthcare Provider Details

I. General information

NPI: 1063128221
Provider Name (Legal Business Name): SHANNON SKOWRON APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON HOLLIDAY

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W225 N16711 CEDAR PARK CT
JACKSON WI
53037-9222
US

IV. Provider business mailing address

W225N16711 CEDAR PARK CT
JACKSON WI
53037-9222
US

V. Phone/Fax

Practice location:
  • Phone: 262-677-1101
  • Fax:
Mailing address:
  • Phone: 262-677-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13219
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: