Basic Information
| Provider Information | |||||||||
| NPI: | 1356094650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIES | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | MARLENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROADHURST | ||||||||
| OtherFirstName: | SHAWN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 583 | ||||||||
| Address2: | |||||||||
| City: | ROSCOE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148827929 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 503 N MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173422121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2022 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 2010023146 | MO | N | Nursing Service Providers | Registered Nurse | Emergency | 163WE0003X | 249192 | WI | N | Nursing Service Providers | Registered Nurse | Emergency | 163WE0003X | 041471170 | IL | N | Nursing Service Providers | Registered Nurse | Emergency | 363LF0000X | 2022006057 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 209024852 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.