Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 209.011505 | IL |
NPI | 1083154033 |
---|---|
Provider Name | Shelby Warner |
First Address | Strawn, IL 61775-4061 |
Second Address | Paxton, IL 60957-1123 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/02/2017 |
Last Update Date | 31/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
370647938 | MOLINA NUMBER (01) | IL |