MEDICARE: SHELLEY MCMAHON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174N00000X	Lactation Consultant (Non-RN)	L-306335	IL

General Provider Information

NPI Number	:	1740933027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY MCMAHON

Provider Business Mailing Address
First Line	:	121 E JACKSON ST
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-3252
Country	:	US
Telephone Number	:	163-091-5912
Fax Number	:

Provider Business Practice Location Address
First Line	:	121 E JACKSON ST
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-3252
Country	:	US
Telephone Number	:	630-915-9123
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2022
Last Update Date	:	01/27/2022

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