Provider Demographics
NPI:1154717817
Name:KUNTZ, SHANNON L
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:KUNTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:STOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 PINE LAKE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-6035
Mailing Address - Country:US
Mailing Address - Phone:402-421-1811
Mailing Address - Fax:402-421-1833
Practice Address - Street 1:2300 S 16TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3704
Practice Address - Country:US
Practice Address - Phone:402-475-1011
Practice Address - Fax:402-481-4783
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE48629363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner