Basic Information
Provider Information | |||||||||
NPI: | 1528449345 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STROUD | ||||||||
FirstName: | SHALAN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STAVENAU | ||||||||
OtherFirstName: | SHALAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 504407 | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631503220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8165027000 | ||||||||
FaxNumber: | 8169327957 | ||||||||
Practice Location | |||||||||
Address1: | 4401 WORNALL RD | ||||||||
Address2: |   | ||||||||
City: | KANSAS CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 641113220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8169327940 | ||||||||
FaxNumber: | 8169327957 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2015 | ||||||||
LastUpdateDate: | 06/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SC0200X | 2012022372 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 2012022372 | 01 | MO | MO LICENSE | OTHER | 53-75906-122 | 01 | KS | KANSAS STATE BOARD OF NURSING | OTHER |