Provider Demographics
NPI:1114449519
Name:SHIRO, LYNDA A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:A
Last Name:SHIRO
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:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-0268
Mailing Address - Country:US
Mailing Address - Phone:815-599-7950
Mailing Address - Fax:815-599-7974
Practice Address - Street 1:1010 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6600
Practice Address - Country:US
Practice Address - Phone:815-599-7740
Practice Address - Fax:815-599-7983
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily