MEDICARE: MRS. FARAH LYNN SHADDIX MSN, RN, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209024820	IL
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F408156	NY
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	259430	AZ
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	202114964NP-PP	OR
5	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95039174	CA
6	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	3015935	KY
7	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	53-81140-101	KS
8	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2020019555	MO
9	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	G161807	IA
10	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP61418023	WA
11	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1097292	TX

General Provider Information

NPI Number	:	1912524059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. FARAH LYNN SHADDIX MSN, RN, PMHNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 791
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-0791
Country	:	US
Telephone Number	:	636-388-4170
Fax Number	:	636-306-4267

Provider Business Practice Location Address
First Line	:	401 CHURCH ST UNIT 791
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-6506
Country	:	US
Telephone Number	:	636-388-4170
Fax Number	:	636-306-4267

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2020
Last Update Date	:	04/08/2026

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