Healthcare Provider Details

I. General information

NPI: 1801100060
Provider Name (Legal Business Name): SHIRLEY A MUSE-BLACKSTONE APN,CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10318 KENT ST
WESTCHESTER IL
60154-4317
US

IV. Provider business mailing address

10318 KENT ST
WESTCHESTER IL
60154-4317
US

V. Phone/Fax

Practice location:
  • Phone: 708-865-8608
  • Fax: 708-865-8608
Mailing address:
  • Phone: 708-865-8608
  • Fax: 708-865-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-000225041.147203
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: