Healthcare Provider Details

I. General information

NPI: 1992321582
Provider Name (Legal Business Name): SHELLY L. BALDWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 E LAKE SHORE DR STE 105
DECATUR IL
62521-3800
US

IV. Provider business mailing address

1770 E LAKE SHORE DR STE 105
DECATUR IL
62521-3800
US

V. Phone/Fax

Practice location:
  • Phone: 217-422-6100
  • Fax:
Mailing address:
  • Phone: 217-422-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209024992
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: