Healthcare Provider Details

I. General information

NPI: 1114994928
Provider Name (Legal Business Name): SHELLY JO REITEN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W. CURTIS
CHAMPAIGN IL
61822-9678
US

IV. Provider business mailing address

PO BOX 6002 NCW4
URBANA IL
61803-6002
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-6203
  • Fax:
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-623-2856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001205
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: