Basic Information
| Provider Information | |||||||||
| NPI: | 1982143335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANTU SANTOLI | ||||||||
| FirstName: | SHANNAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SOUTH LAKE DR. | ||||||||
| Address2: | |||||||||
| City: | CUDAHY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531106108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975266 | ||||||||
| FaxNumber: | 6189975285 | ||||||||
| Practice Location | |||||||||
| Address1: | 5050 SOUTH LAKE DR. | ||||||||
| Address2: | #100510 | ||||||||
| City: | CUDAHY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531106108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147692239 | ||||||||
| FaxNumber: | 6189975285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2017 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 209015629 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 176B00000X | 148990-32 | WI | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1000-947-56 | 05 | WI | MEDICAID |