Provider Demographics
NPI:1699231043
Name:WIXOM, SHANNON R (APRN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:WIXOM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:R
Other - Last Name:BECHTOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:5801 RESEARCH PARK BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-6003
Mailing Address - Country:US
Mailing Address - Phone:608-729-6344
Mailing Address - Fax:
Practice Address - Street 1:5801 RESEARCH PARK BLVD STE 400
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-6003
Practice Address - Country:US
Practice Address - Phone:608-729-6344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI151252-30163W00000X
WI9059-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse