Healthcare Provider Details

I. General information

NPI: 1619645918
Provider Name (Legal Business Name): SHELBY LYNN ICENHOWER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-2115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021031470
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: