MEDICARE: MRS. SHANNON LEE KEIDEL R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265493209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON LEE KEIDEL R.N.

Provider Business Mailing Address
First Line	:	7420 E WIND LAKE RD
Second Line	:
City	:	WATERFORD
State	:	WI
Zip	:	53185-1512
Country	:	US
Telephone Number	:	262-895-2692
Fax Number	:

Provider Business Practice Location Address
First Line	:	7420 E WIND LAKE RD
Second Line	:
City	:	WATERFORD
State	:	WI
Zip	:	53185-1512
Country	:	US
Telephone Number	:	262-895-2692
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	07/09/2007

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