Basic Information
| Provider Information | |||||||||
| NPI: | 1518306414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODSIL | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARDY | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1343 S 51ST AVE | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681062425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088467684 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9801 GILES RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | LA VISTA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681282925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029558400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | TEP#6973 | NE | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 29266 | NE | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.