Provider Demographics
NPI:1790265858
Name:SHIPMAN, AMELIA
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:SHIPMAN
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 1:118 N 2ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2894
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:
Practice Address - Street 1:141 COMMUNICATION DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-3670
Practice Address - Country:US
Practice Address - Phone:573-603-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020015213124Q00000X
MO2017005949124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist