Provider Demographics
NPI:1275138042
Name:SHINN, SAMANTHA JO
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:SHINN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2610
Mailing Address - Country:US
Mailing Address - Phone:309-335-7426
Mailing Address - Fax:
Practice Address - Street 1:700 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2610
Practice Address - Country:US
Practice Address - Phone:309-335-7426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022439363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily