Provider Demographics
NPI:1205821121
Name:WATLEY, SHANNON (DO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WATLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13707 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3188
Mailing Address - Country:US
Mailing Address - Phone:815-337-1871
Mailing Address - Fax:815-338-6297
Practice Address - Street 1:360 STATION DRIVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6260
Practice Address - Country:US
Practice Address - Phone:815-477-2310
Practice Address - Fax:815-356-2335
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106885207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
K08710Medicare ID - Type Unspecified
H76417Medicare UPIN
IL962341Medicare PIN