Provider Demographics
NPI:1558394510
Name:MANCUSO, SHAYNA (DO)
Entity Type:Individual
Prefix:
First Name:SHAYNA
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHAYNA
Other - Middle Name:
Other - Last Name:HOLLINGSWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:811 S RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-2755
Mailing Address - Country:US
Mailing Address - Phone:312-399-1732
Mailing Address - Fax:
Practice Address - Street 1:660 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045
Practice Address - Country:US
Practice Address - Phone:847-535-6352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112082207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112082Medicaid
K11324Medicare ID - Type Unspecified
IL036112082Medicaid