Provider Demographics
NPI:1356094650
Name:NIES, SHAWN MARLENE (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:MARLENE
Last Name:NIES
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:
Other - Last Name:BROADHURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 583
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073
Mailing Address - Country:US
Mailing Address - Phone:314-882-7929
Mailing Address - Fax:
Practice Address - Street 1:503 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2006
Practice Address - Country:US
Practice Address - Phone:217-342-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010023146163WE0003X
WI249192163WE0003X
IL041471170163WE0003X
MO2022006057363LF0000X
IL209024852363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency