Basic Information
Provider Information | |||||||||
NPI: | 1811409162 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHIMEALL | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SEELEY | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9697 SAINT CATHERINES DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | PLEASANT PRAIRIE | ||||||||
State: | WI | ||||||||
PostalCode: | 531582118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626563590 | ||||||||
FaxNumber: | 2626563591 | ||||||||
Practice Location | |||||||||
Address1: | 9697 SAINT CATHERINES DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | PLEASANT PRAIRIE | ||||||||
State: | WI | ||||||||
PostalCode: | 531582118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626563590 | ||||||||
FaxNumber: | 2626563591 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2017 | ||||||||
LastUpdateDate: | 04/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 4012-23 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 4012-23 | 01 | WI | WI LICENSE | OTHER | K400441598 | 01 | WI | MEDICARE | OTHER |