Provider Demographics
NPI:1013106707
Name:GROVES, SHANNON MARIE (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:GROVES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:GUNTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2202 ESSINGTON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-2426
Mailing Address - Country:US
Mailing Address - Phone:815-676-5310
Mailing Address - Fax:815-725-1321
Practice Address - Street 1:2202 ESSINGTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1634
Practice Address - Country:US
Practice Address - Phone:815-676-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL08500306363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant