Provider Demographics
NPI:1790710531
Name:WIDERA, SHANNA MARIE (RN, APN)
Entity Type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:MARIE
Last Name:WIDERA
Suffix:
Gender:F
Credentials:RN, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1221 N DEARBORN ST APT 603N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-8375
Mailing Address - Country:US
Mailing Address - Phone:773-398-7880
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:BOX #59
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-6778
Practice Address - Fax:312-227-9413
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004579363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics