Basic Information
Provider Information
NPI: 1033559802
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LAESCH
FirstName: SHANNON
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: APRN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2005 JACOBSSEN DR STE A
Address2:  
City: NORMAL
State: IL
PostalCode: 617616288
CountryCode: US
TelephoneNumber: 3098070384
FaxNumber: 3096619571
Practice Location
Address1: 2005 JACOBSSEN DR STE A
Address2:  
City: NORMAL
State: IL
PostalCode: 617616288
CountryCode: US
TelephoneNumber: 3098070384
FaxNumber: 3096619571
Other Information
ProviderEnumerationDate: 06/26/2013
LastUpdateDate: 12/07/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
364SA2200X209010219ILY Physician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health

No ID Information.


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