Healthcare Provider Details

I. General information

NPI: 1396880266
Provider Name (Legal Business Name): STEPHANIE JAVUE BURRELL LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 W S 3RD ST
SHELBYVILLE IL
62565-9205
US

IV. Provider business mailing address

PO BOX 650 1810 W S 3RD ST
SHELBYVILLE IL
62565-9205
US

V. Phone/Fax

Practice location:
  • Phone: 217-774-2113
  • Fax: 217-774-2256
Mailing address:
  • Phone: 217-774-2113
  • Fax: 217-774-2256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: