Provider Demographics
NPI:1801250691
Name:TIMM, SHANNON (LPN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:TIMM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2798 COUNTY ROAD K
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-9409
Mailing Address - Country:US
Mailing Address - Phone:715-966-2779
Mailing Address - Fax:
Practice Address - Street 1:N2798 COUNTY ROAD K
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-9409
Practice Address - Country:US
Practice Address - Phone:715-966-2779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320131-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse