Healthcare Provider Details

I. General information

NPI: 1356796874
Provider Name (Legal Business Name): AMY L. MCLEAN APRN, NP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY L SHAFER

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 HAWTHORN RD
SALEM IL
62881-1028
US

IV. Provider business mailing address

1275 HAWTHORN RD
SALEM IL
62881-1028
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-4545
  • Fax: 618-545-4577
Mailing address:
  • Phone: 618-548-4545
  • Fax: 618-545-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014035
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number209014035
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: