Provider Demographics
NPI:1003572470
Name:WHITLEY, SHANNON LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-2565
Mailing Address - Country:US
Mailing Address - Phone:815-822-1077
Mailing Address - Fax:
Practice Address - Street 1:1650 MIDTOWN RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1200
Practice Address - Country:US
Practice Address - Phone:815-223-6843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023633363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily