Provider Demographics
NPI:1336856962
Name:SHAMON, RITA (NP)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:SHAMON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 N RIVERSIDE DR STE 216
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5918
Mailing Address - Country:US
Mailing Address - Phone:847-625-8300
Mailing Address - Fax:847-625-8862
Practice Address - Street 1:501 N RIVERSIDE DR STE 216
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5918
Practice Address - Country:US
Practice Address - Phone:847-625-8300
Practice Address - Fax:847-625-8862
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026197363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL98916Medicaid