Healthcare Provider Details

I. General information

NPI: 1306314778
Provider Name (Legal Business Name): KRISTY DAWN SHAFER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER DR STE 107
MATTOON IL
61938-4644
US

IV. Provider business mailing address

1000 HEALTH CENTER DR
MATTOON IL
61938-4644
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-4096
  • Fax: 217-238-5485
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277-003062
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: