Healthcare Provider Details

I. General information

NPI: 1174261044
Provider Name (Legal Business Name): SHANTEL MILES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2022
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 EAST BROAD STREET
NAYLOR MO
63953
US

IV. Provider business mailing address

110 S 2ND ST
ELLINGTON MO
63638-9400
US

V. Phone/Fax

Practice location:
  • Phone: 573-399-2311
  • Fax: 573-399-2076
Mailing address:
  • Phone: 573-663-2313
  • Fax: 573-663-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2011016469
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022011643
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: