Healthcare Provider Details

I. General information

NPI: 1316975683
Provider Name (Legal Business Name): SHANNON PETERSON DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N275 MILITARY RD SUITE 2
SHERWOOD WI
54169-9603
US

IV. Provider business mailing address

N275 MILITARY RD SUITE 2
SHERWOOD WI
54169-9603
US

V. Phone/Fax

Practice location:
  • Phone: 920-989-1599
  • Fax: 920-989-1593
Mailing address:
  • Phone: 920-989-1599
  • Fax: 920-989-1593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3809-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: