Provider Demographics
NPI:1891090312
Name:SHAY, KIM MARIA
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:MARIA
Last Name:SHAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MARIA
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:1201 N NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1533
Mailing Address - Country:US
Mailing Address - Phone:309-671-2310
Mailing Address - Fax:309-674-3560
Practice Address - Street 1:1201 N NORTH ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1533
Practice Address - Country:US
Practice Address - Phone:309-671-2310
Practice Address - Fax:309-674-3560
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008069363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily