Provider Demographics
NPI:1033826060
Name:MALONE, SHANNON HARRISON (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:HARRISON
Last Name:MALONE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 N ILLINOIS RTE 31
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012
Mailing Address - Country:US
Mailing Address - Phone:224-238-3211
Mailing Address - Fax:
Practice Address - Street 1:442 N ILLINOIS RTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-6001
Practice Address - Country:US
Practice Address - Phone:224-238-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.026522363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily