Basic Information
| Provider Information | |||||||||
| NPI: | 1558728337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIERKER | ||||||||
| FirstName: | SHANNA | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 927 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172246423 | ||||||||
| FaxNumber: | 2172211344 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172246423 | ||||||||
| FaxNumber: | 2172211344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2016 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041404031 | IL | N | Nursing Service Providers | Registered Nurse | 163W00000X | 2015032867 | MO | N | Nursing Service Providers | Registered Nurse | 363LF0000X | A143402 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 209-014331 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.