Healthcare Provider Details

I. General information

NPI: 1255148656
Provider Name (Legal Business Name): MARY GRACE SHANABARGER APNP, AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 N JEFFERSON ST STE 300
MILWAUKEE WI
53202-3710
US

IV. Provider business mailing address

N16W24131 RIVERWOOD DR
WAUKESHA WI
53188-1106
US

V. Phone/Fax

Practice location:
  • Phone: 414-272-8950
  • Fax:
Mailing address:
  • Phone: 262-696-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number16303
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number16303-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number256531-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: