Healthcare Provider Details

I. General information

NPI: 1588891097
Provider Name (Legal Business Name): SHANNON M BIBIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 AMERICAN AVE
WAUKESHA WI
53188-5031
US

IV. Provider business mailing address

1336 PARK AVE
SOUTH MILWAUKEE WI
53172-1133
US

V. Phone/Fax

Practice location:
  • Phone: 262-928-2594
  • Fax: 414-805-5809
Mailing address:
  • Phone: 414-940-0278
  • Fax: 414-301-9508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number156515
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number156515
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: