Provider Demographics
NPI:1023375409
Name:SHAFER, NATASHA CHARLYN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:CHARLYN
Last Name:SHAFER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5336
Mailing Address - Country:US
Mailing Address - Phone:573-472-6003
Mailing Address - Fax:573-472-7159
Practice Address - Street 1:1340 CEDAR CT STE 202
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-529-7821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012006260363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209010067OtherDEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION
3903223660OtherTHE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION
2012001998OtherAMERICAN NURSES CREDENTIALING CENTER
IL$$$$$$$$$001Medicaid