Healthcare Provider Details

I. General information

NPI: 1346387495
Provider Name (Legal Business Name): MRS. SHAE MICHELLE WESLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 ROUTE 54 WEST
CLINTON IL
61727
US

IV. Provider business mailing address

9 CURRENCY DR #308
BLOOMINGTON IL
61704-9481
US

V. Phone/Fax

Practice location:
  • Phone: 217-935-2218
  • Fax: 217-935-2788
Mailing address:
  • Phone: 309-318-0697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: