Provider Demographics
NPI:1174261044
Name:MILES, SHANTEL (FNP)
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 TIMARA LN
Mailing Address - Street 2:
Mailing Address - City:HARVIELL
Mailing Address - State:MO
Mailing Address - Zip Code:63945-8209
Mailing Address - Country:US
Mailing Address - Phone:573-718-2904
Mailing Address - Fax:
Practice Address - Street 1:1212N SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-2769
Practice Address - Country:US
Practice Address - Phone:573-624-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-21
Last Update Date:2022-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022011643363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily