Healthcare Provider Details

I. General information

NPI: 1356094650
Provider Name (Legal Business Name): SHAWN MARLENE NIES FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAWN BROADHURST

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 N MAPLE ST
EFFINGHAM IL
62401-2006
US

IV. Provider business mailing address

PO BOX 583
ROSCOE IL
61073
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-2121
  • Fax:
Mailing address:
  • Phone: 314-882-7929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2010023146
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number249192
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number041471170
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022006057
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209024852
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: