Healthcare Provider Details

I. General information

NPI: 1649100926
Provider Name (Legal Business Name): SHANNON WIEGEL BSN RN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 W BROADWAY AVE
MEDFORD WI
54451-1311
US

IV. Provider business mailing address

124 W STATE ST
MEDFORD WI
54451-1760
US

V. Phone/Fax

Practice location:
  • Phone: 715-748-2316
  • Fax:
Mailing address:
  • Phone: 715-748-6839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number166319-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: