Provider Demographics
NPI:1194306415
Name:HEIDT, SHANNON GAIL (APRN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:GAIL
Last Name:HEIDT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:GAIL
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2940
Mailing Address - Country:US
Mailing Address - Phone:608-756-6838
Mailing Address - Fax:608-756-6236
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-756-6838
Practice Address - Fax:608-756-6236
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI258903-30163W00000X
WI10772-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse