Healthcare Provider Details

I. General information

NPI: 1760211015
Provider Name (Legal Business Name): BLAKE SHANAHAN MSN, APRN, NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 75TH ST
KENOSHA WI
53142-7884
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-948-5600
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number15676-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: