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General NPI Number Information
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NPI Number | 1326994559
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Entity Type | Individual
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Provider Name | SHANNON WILSON
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Gender | Female
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Dates
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Enumeration Date | 03/09/2026
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Last Update Date | 03/09/2026
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Provider Practice Location Address
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Address Line | 32 PORTWEST CT
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City | SAINT CHARLES
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State | MO
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Zip | 63303-5985
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Country | US
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Telephone | 636-410-8292
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Fax |
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Provider Business Mailing Address
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Address Line | 1617 GRAPE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63147-1405
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Country | US
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Telephone | 314-280-6366
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 2087
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number | 2087
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License Number State | MO
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