MCKENNA IVY SHOFROTH RN NPI 1962158501

NPI Information

  • NPI: 1962158501
  • Provider Name: MCKENNA IVY SHOFROTH, RN
  • Classification: Registered Nurse - 163WG0000X
  • Specialization: General Practice
  • Entity Type: Individual
  • Address: 20 PROFESSIONAL PARK DR STE B
    MARYVILLE, IL
    ZIP 62062
  • Phone: (618) 288-1480

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NPI Details

Mckenna Ivy Shofroth, RN is a general practice registered nurse in Maryville, IL. Mckenna Ivy Shofroth, RN NPI is 1962158501. The provider is registered as an individual entity type.

The NPPES NPI record indicates the provider is a female.

The provider's business location address is:

20 PROFESSIONAL PARK DR STE B
MARYVILLE, IL
ZIP 62062-830
Phone: (618) 288-1480
Fax: (888) 718-4696

The enumeration date for this NPI number is 2/22/2022 and was last updated on 2/22/2022.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1163WG0000XRegistered NurseGeneral Practice041521566ILLINOISYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
11417916099MEDICAIDILLINOIS

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

NPI Synchronization or Removal

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