Provider Demographics
NPI:1598914905
Name:HENSON, SHALISA ANNE (CNM)
Entity Type:Individual
Prefix:
First Name:SHALISA
Middle Name:ANNE
Last Name:HENSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3006
Mailing Address - Country:US
Mailing Address - Phone:618-436-8350
Mailing Address - Fax:
Practice Address - Street 1:430 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3006
Practice Address - Country:US
Practice Address - Phone:618-436-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007259363L00000X
MO2019040165367A00000X
IL209017353367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00651305OtherRAILROAD MEDICARE
IL207988OtherMEDICARE GROUP NUMBER
IL207988001OtherMEDICARE PTAN NUMBER
ILCG2264OtherRR GROUP ID