Provider Demographics
NPI:1447693635
Name:REISDORF, SHAWN (RN)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:REISDORF
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6607 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3353
Mailing Address - Country:US
Mailing Address - Phone:608-843-0285
Mailing Address - Fax:
Practice Address - Street 1:6607 COOPER AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3353
Practice Address - Country:US
Practice Address - Phone:608-843-0285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI123233-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse