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General NPI Number Information
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NPI Number | 1962738856
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Entity Type | Individual
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Provider Name | SHANNON EILEEN STALEY M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/27/2009
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Last Update Date | 12/29/2021
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Provider Practice Location Address
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Address Line | 5841 S MARYLAND AVE
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City | CHICAGO
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State | IL
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Zip | 60637-1447
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Country | US
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Telephone | 773-702-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 1727 N HERMITAGE AVE APT #2
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City | CHICAGO
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State | IL
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Zip | 60622-1411
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Country | US
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Telephone | 708-363-1328
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 125056477
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License Number State | IL
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