Provider Demographics
NPI:1811395155
Name:MALLOY, SHANNON K (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:MALLOY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N. KINGSBURY STREET UNIT 967
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610
Mailing Address - Country:US
Mailing Address - Phone:773-531-6923
Mailing Address - Fax:
Practice Address - Street 1:1301 W. 22ND STREET STE 610
Practice Address - Street 2:CONTINENTAL ANESTHESIA
Practice Address - City:OAKBROOK
Practice Address - State:IL
Practice Address - Zip Code:60523
Practice Address - Country:US
Practice Address - Phone:630-537-1720
Practice Address - Fax:773-326-3518
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012324367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered