Healthcare Provider Details

I. General information

NPI: 1104691815
Provider Name (Legal Business Name): SHIRLISA LOVE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MEADOWCREST DRIVE
BELLEVILLE IL
62221
US

IV. Provider business mailing address

112 MEADOWCREST DR
BELLEVILLE IL
62221-6749
US

V. Phone/Fax

Practice location:
  • Phone: 618-298-7601
  • Fax:
Mailing address:
  • Phone: 161-855-0502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209029158
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023046705
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: