Provider Demographics
NPI:1083180228
Name:SHEWALTER, ANDREA M (APRN)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:M
Last Name:SHEWALTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11189 JASMINE DR
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9410
Mailing Address - Country:US
Mailing Address - Phone:815-501-3115
Mailing Address - Fax:
Practice Address - Street 1:535 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5076
Practice Address - Country:US
Practice Address - Phone:815-387-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041351530363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily