Provider Demographics
NPI:1104691815
Name:LOVE, SHIRLISA
Entity type:Individual
Prefix:
First Name:SHIRLISA
Middle Name:
Last Name:LOVE
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 1:112 MEADOWCREST DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-6749
Mailing Address - Country:US
Mailing Address - Phone:161-855-0502
Mailing Address - Fax:
Practice Address - Street 1:MENARD CORRECTIONAL CENTER
Practice Address - Street 2:711 E KASKASKIA ST.
Practice Address - City:MENARD
Practice Address - State:IL
Practice Address - Zip Code:62259
Practice Address - Country:US
Practice Address - Phone:618-826-5071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023046705363LP0808X
IL209029158363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health