Provider Demographics
NPI:1558728337
Name:DIERKER, SHANNA JAY (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:JAY
Last Name:DIERKER
Suffix:
Gender:
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-702-6371
Mailing Address - Fax:920-358-1173
Practice Address - Street 1:3925 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7863
Practice Address - Country:US
Practice Address - Phone:920-702-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA143402363LF0000X
IL209-014331363LF0000X
WI15817363LF0000X
MO2015032867163W00000X
IL041404031163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse