Provider Demographics
NPI:1255148656
Name:SHANABARGER, MARY GRACE (APNP, AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:SHANABARGER
Suffix:
Gender:F
Credentials:APNP, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N16W24131 RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1106
Mailing Address - Country:US
Mailing Address - Phone:262-696-0808
Mailing Address - Fax:
Practice Address - Street 1:N16W24131 RIVERWOOD DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1106
Practice Address - Country:US
Practice Address - Phone:262-366-7437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-18
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI256531-30163WG0000X
WI16303-33363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice