1477689883 NPI number — TABITHA M. SHEEN APNP

Table of content: TABITHA M. SHEEN APNP (NPI 1477689883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477689883 NPI number — TABITHA M. SHEEN APNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEEN
Provider First Name:
TABITHA
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477689883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 15TH AVE.
Provider Second Line Business Mailing Address:
STE. 180, LAKESHORE MEDICAL CLINIC
Provider Business Mailing Address City Name:
SOUTH MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53172-1160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-768-5430
Provider Business Mailing Address Fax Number:
414-762-4224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 E. LAYTON AVE.
Provider Second Line Business Practice Location Address:
LAKESHORE MEDICAL CLINIC
Provider Business Practice Location Address City Name:
ST. FRANCIS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53235-6053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-744-6589
Provider Business Practice Location Address Fax Number:
414-747-8848
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  108285-30 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 2803 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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