Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | 209000900 | IL |
NPI | 1215265327 |
---|---|
Provider Name | Ms. Mildred Elaine Shafer |
First Address | Mapleton, IL 61547-9347 |
Second Address | Peoria, IL 61637-0002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2009 |
Last Update Date | 01/12/2009 |