Provider Demographics
NPI:1194453738
Name:GROSSE, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GROSSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 7TH STREET
Mailing Address - Street 2:-
Mailing Address - City:SYRACUSE
Mailing Address - State:NE
Mailing Address - Zip Code:68446
Mailing Address - Country:US
Mailing Address - Phone:402-269-5866
Mailing Address - Fax:
Practice Address - Street 1:1430 EDUCATION DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NE
Practice Address - Zip Code:68446-4000
Practice Address - Country:US
Practice Address - Phone:402-269-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15980164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE15980Medicaid