Healthcare Provider Details

I. General information

NPI: 1659498822
Provider Name (Legal Business Name): SHAREE LANEE CHANCE-LAWSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4328 OLD GREEN BAY RD
MT PLEASANT WI
53403-9489
US

IV. Provider business mailing address

4328 OLD GREEN BAY RD
MT PLEASANT WI
53403-9489
US

V. Phone/Fax

Practice location:
  • Phone: 262-687-7606
  • Fax: 262-687-7615
Mailing address:
  • Phone: 262-687-7606
  • Fax: 262-687-7615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036111059
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: