Healthcare Provider Details

I. General information

NPI: 1558198739
Provider Name (Legal Business Name): SHANNON KEITH ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3965 75TH ST STE 103
AURORA IL
60504-7926
US

IV. Provider business mailing address

3965 75TH ST STE 103
AURORA IL
60504-7926
US

V. Phone/Fax

Practice location:
  • Phone: 630-375-1625
  • Fax: 630-429-9870
Mailing address:
  • Phone: 630-375-1625
  • Fax: 630-429-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209030612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: