Provider Demographics
NPI:1013364926
Name:SHANNON, KRISTIN WARNER (DNP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:WARNER
Last Name:SHANNON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2740 W FOSTER AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3500
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:6141 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4303
Practice Address - Country:US
Practice Address - Phone:773-293-8788
Practice Address - Fax:773-293-8791
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.013832363LF0000X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily