Provider Demographics
NPI:1629736285
Name:SHALLCROSS, DIANE MARIE (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MARIE
Last Name:SHALLCROSS
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7480 W COLLEGE DR STE 203
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1195
Mailing Address - Country:US
Mailing Address - Phone:708-361-0540
Mailing Address - Fax:
Practice Address - Street 1:7480 W COLLEGE DR STE 203
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1195
Practice Address - Country:US
Practice Address - Phone:708-361-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.024336363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health