Provider Demographics
NPI:1174999148
Name:PALMER, SHIRLEY
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:PALMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 COUNTY ROAD H
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54443-9697
Mailing Address - Country:US
Mailing Address - Phone:715-457-6694
Mailing Address - Fax:
Practice Address - Street 1:2310 COUNTY ROAD H
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:WI
Practice Address - Zip Code:54443-9697
Practice Address - Country:US
Practice Address - Phone:715-457-6694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73107-30163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI73107-30Medicaid