Healthcare Provider Details

I. General information

NPI: 1265493209
Provider Name (Legal Business Name): SHANNON LEE KEIDEL R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: SHANNON LEE SCHUETZ R.N.

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7420 E WIND LAKE RD
WATERFORD WI
53185-1512
US

IV. Provider business mailing address

7420 E WIND LAKE RD
WATERFORD WI
53185-1512
US

V. Phone/Fax

Practice location:
  • Phone: 262-895-2692
  • Fax:
Mailing address:
  • Phone: 262-895-2692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: