Healthcare Provider Details

I. General information

NPI: 1215783469
Provider Name (Legal Business Name): SHELLI DAWN MANGIAMELI-MULLINS LCPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 02/08/2025
Certification Date: 02/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 E OGDEN AVE
NAPERVILLE IL
60563-3237
US

IV. Provider business mailing address

43W132 BEITH RD
ELBURN IL
60119-9567
US

V. Phone/Fax

Practice location:
  • Phone: 313-627-2992
  • Fax:
Mailing address:
  • Phone: 313-627-2992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number041533312
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number295000019
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: