Healthcare Provider Details

I. General information

NPI: 1366806374
Provider Name (Legal Business Name): SHELLY FLAGG FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N 9TH ST FL 2
SPRINGFIELD IL
62702-5310
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-6041
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014012
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: