=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669210522
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON GRIMES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2024
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5841 S MARYLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-824-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1816 S CALUMET AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-899-3450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LN0000X
-----------------------------------------------------
Taxonomy Name | Neonatal Nurse Practitioner
-----------------------------------------------------
License Number | 209030081
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------