Provider Demographics
NPI:1295144608
Name:MCCLONE, SHANA
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:MCCLONE
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 1:8545 S APPLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-2633
Mailing Address - Country:US
Mailing Address - Phone:414-489-4048
Mailing Address - Fax:414-489-4153
Practice Address - Street 1:5900 S LAKE DR
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-3171
Practice Address - Country:US
Practice Address - Phone:414-489-4048
Practice Address - Fax:414-489-4153
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5677-33364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health