Healthcare Provider Details

I. General information

NPI: 1114449519
Provider Name (Legal Business Name): LYNDA A SHIRO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 FAIRWAY DR
FREEPORT IL
61032-6600
US

IV. Provider business mailing address

PO BOX 268
FREEPORT IL
61032-0268
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-7740
  • Fax: 815-599-7983
Mailing address:
  • Phone: 815-599-7950
  • Fax: 815-599-7974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209016073
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: