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NPI Code Detail

MEDICARE: SHANNON WILSON

MEDICARE: SHANNON WILSON
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
1310400000XAssisted Living Facility2087MO
2261QA0600XAdult Day Care Clinic/Center2087MO

General Provider Information

NPI Number : 1326994559
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANNON WILSON
Provider Business Mailing Address
First Line : 1617 GRAPE AVE
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63147-1405
Country : US
Telephone Number : 314-280-6366
Fax Number :
Provider Business Practice Location Address
First Line : 32 PORTWEST CT
Second Line :
City : SAINT CHARLES
State : MO
Zip : 63303-5985
Country : US
Telephone Number : 636-410-8292
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/09/2026
Last Update Date : 03/09/2026

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Directions to “ SHANNON WILSON ” Practice Location

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