Individual
SHELLY SHALLAT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
10 SAINT CLARE CT, WASHINGTON, IL 61571-9239
(309) 886-4000
(309) 886-4118
Mailing address
320 E ARMSTRONG AVE, PEORIA, IL 61603-3172
(309) 680-7600
(309) 495-8614
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
036-101025
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036101025
—
IL
01
—
07223454
BLUE CROSS
IL
01
—
IL20810
BEECH STREET
IL
Enumeration date
10/20/2006
Last updated
11/11/2015
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