Healthcare Provider Details

I. General information

NPI: 1407456171
Provider Name (Legal Business Name): SHAUNA VANDERMEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 75TH ST
WILLOWBROOK IL
60527-2325
US

IV. Provider business mailing address

40 75TH ST
WILLOWBROOK IL
60527-2325
US

V. Phone/Fax

Practice location:
  • Phone: 630-581-5372
  • Fax: 630-568-3247
Mailing address:
  • Phone: 630-581-5372
  • Fax: 630-568-3247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041449789
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209022383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: