Healthcare Provider Details

I. General information

NPI: 1083705487
Provider Name (Legal Business Name): MARSHA D SHIVLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 BARRON RD STE 120
POPLAR BLUFF MO
63901-1922
US

IV. Provider business mailing address

110 S 2ND ST
ELLINGTON MO
63638-9400
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-6536
  • Fax: 573-785-0100
Mailing address:
  • Phone: 573-663-2313
  • Fax: 573-663-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number075449
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: