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General NPI Number Information
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NPI Number | 1104691815
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Entity Type | Individual
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Provider Name | SHIRLISA LOVE
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Gender | Female
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Dates
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Enumeration Date | 11/22/2023
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Last Update Date | 01/08/2024
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Provider Practice Location Address
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Address Line | MENARD CORRECTIONAL CENTER 711 E KASKASKIA ST.
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City | MENARD
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State | IL
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Zip | 62259
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Country | US
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Telephone | 618-826-5071
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Fax |
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Provider Business Mailing Address
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Address Line | 112 MEADOWCREST DR
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City | BELLEVILLE
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State | IL
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Zip | 62221-6749
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Country | US
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Telephone | 161-855-0502
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 2023046705
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 209029158
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License Number State | IL
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