MEDICARE: SHONTEL MARLENA RAY AGPCNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	2015001948	MO
2	363LA2200X	Adult Health Nurse Practitioner	209013100	IL
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	277002617	IL

General Provider Information

NPI Number	:	1932593910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHONTEL MARLENA RAY AGPCNP

Provider Business Mailing Address
First Line	:	7234 W NORTH AVE STE 208
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-4202
Country	:	US
Telephone Number	:	618-746-0052
Fax Number	:	618-300-7060

Provider Business Practice Location Address
First Line	:	7234 W NORTH AVE STE 208
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-4202
Country	:	US
Telephone Number	:	618-746-0052
Fax Number	:	618-300-7060

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2015
Last Update Date	:	08/26/2025

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