Provider Demographics
NPI:1588476048
Name:REINKE, SHANNA
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:REINKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:REINKE
Other - Last Name:KILLAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5139 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-2119
Mailing Address - Country:US
Mailing Address - Phone:515-953-8087
Mailing Address - Fax:
Practice Address - Street 1:5139 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-2119
Practice Address - Country:US
Practice Address - Phone:515-953-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA182677363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily