Basic Information
| Provider Information | |||||||||
| NPI: | 1841713450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANGEN | ||||||||
| FirstName: | SHELLANE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | BSN, MSN, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2183 WAGON TRAIL RD | ||||||||
| Address2: | |||||||||
| City: | WHITE HEATH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618849313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176216874 | ||||||||
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| Practice Location | |||||||||
| Address1: | 819 BLOOMINGTON RD | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618202101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173561558 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2017 | ||||||||
| LastUpdateDate: | 07/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209015253 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.