Provider Demographics
NPI:1023222817
Name:FARRIS, SHONDA LYNN (RN, MSN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SHONDA
Middle Name:LYNN
Last Name:FARRIS
Suffix:
Gender:F
Credentials:RN, MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13258 BLACKSTONE LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-5332
Mailing Address - Country:US
Mailing Address - Phone:765-208-5131
Mailing Address - Fax:
Practice Address - Street 1:11200 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8208
Practice Address - Country:US
Practice Address - Phone:815-464-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK53532Medicare PIN
ILK53533Medicare PIN