Healthcare Provider Details

I. General information

NPI: 1699231043
Provider Name (Legal Business Name): SHANNON R. WIXOM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON R. BECHTOLT APRN

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 RESEARCH PARK BLVD STE 400
MADISON WI
53719-6003
US

IV. Provider business mailing address

5801 RESEARCH PARK BLVD STE 400
MADISON WI
53719-6003
US

V. Phone/Fax

Practice location:
  • Phone: 608-729-6344
  • Fax:
Mailing address:
  • Phone: 608-729-6344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number151252-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9059-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: