Provider Demographics
NPI:1154744282
Name:HAGGARD, SHANNON (NP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:HAGGARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 E JONES ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IL
Mailing Address - Zip Code:60953-1046
Mailing Address - Country:US
Mailing Address - Phone:815-889-4241
Mailing Address - Fax:815-889-4252
Practice Address - Street 1:34 E JONES ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IL
Practice Address - Zip Code:60953-1046
Practice Address - Country:US
Practice Address - Phone:815-889-4241
Practice Address - Fax:815-889-4252
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011214363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILF400123558Medicare PIN