Healthcare Provider Details

I. General information

NPI: 1770888901
Provider Name (Legal Business Name): SHANNON LYN BARTOLUCCI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON LYN CHEJFEC NP

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 OGDEN AVE STE A
DOWNERS GROVE IL
60515-2602
US

IV. Provider business mailing address

415 ANTHONY ST
GLEN ELLYN IL
60137-4419
US

V. Phone/Fax

Practice location:
  • Phone: 630-832-1775
  • Fax: 630-832-1775
Mailing address:
  • Phone: 630-864-7410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.004191
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.004191
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: