Provider Demographics
NPI:1053952515
Name:CLARKSON, SHANA (NP)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:CLARKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-223-1200
Mailing Address - Fax:
Practice Address - Street 1:2500 ROUTE 99 S
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:IL
Practice Address - Zip Code:62353-1462
Practice Address - Country:US
Practice Address - Phone:217-773-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020182363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily