Healthcare Provider Details

I. General information

NPI: 1013364926
Provider Name (Legal Business Name): KRISTIN WARNER SHANNON DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6141 N CICERO AVE
CHICAGO IL
60646-4303
US

IV. Provider business mailing address

2740 W FOSTER AVE STE 310
CHICAGO IL
60625-3500
US

V. Phone/Fax

Practice location:
  • Phone: 773-293-8788
  • Fax: 773-293-8791
Mailing address:
  • Phone: 773-878-8200
  • Fax: 773-293-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.013832
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number209.013832
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: