Provider Demographics
NPI:1134758881
Name:PETTIT, SHANNON C (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:PETTIT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 E BRUSH HILL RD STE 308
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5662
Mailing Address - Country:US
Mailing Address - Phone:331-221-9006
Mailing Address - Fax:331-221-2734
Practice Address - Street 1:133 E BRUSH HILL RD STE 308
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5662
Practice Address - Country:US
Practice Address - Phone:331-221-9006
Practice Address - Fax:331-221-2734
Is Sole Proprietor?:No
Enumeration Date:2020-04-05
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036165765207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program