Healthcare Provider Details

I. General information

NPI: 1982267696
Provider Name (Legal Business Name): SHELBY L. CHAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELBY WALLACE CRNA

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 STATE ROUTE 91 STE 250
PEORIA IL
61615-7831
US

IV. Provider business mailing address

8600 STATE ROUTE 91 STE 250
PEORIA IL
61615-7831
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-5393
  • Fax:
Mailing address:
  • Phone: 309-692-5393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-019301
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: