Healthcare Provider Details

I. General information

NPI: 1023375409
Provider Name (Legal Business Name): NATASHA CHARLYN SHAFER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 CEDAR CT STE 202
CARBONDALE IL
62901
US

IV. Provider business mailing address

1340 CEDAR CT
CARBONDALE IL
62901-5336
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-7821
  • Fax:
Mailing address:
  • Phone: 573-472-6003
  • Fax: 573-472-7159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2012006260
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: