Healthcare Provider Details

I. General information

NPI: 1205821121
Provider Name (Legal Business Name): SHANNON WATLEY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 STATION DRIVE 3RD FLOOR
CRYSTAL LAKE IL
60014-6260
US

IV. Provider business mailing address

13707 W JACKSON ST
WOODSTOCK IL
60098-3188
US

V. Phone/Fax

Practice location:
  • Phone: 815-477-2310
  • Fax: 815-356-2335
Mailing address:
  • Phone: 815-337-1871
  • Fax: 815-338-6297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036106885
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: