Provider Demographics
NPI:1356702252
Name:PETER, SHAYNA
Entity type:Individual
Prefix:
First Name:SHAYNA
Middle Name:
Last Name:PETER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W NORTH AVE # 197
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1293
Mailing Address - Country:US
Mailing Address - Phone:312-870-0416
Mailing Address - Fax:
Practice Address - Street 1:7750 S WOLCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-5229
Practice Address - Country:US
Practice Address - Phone:773-819-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
DCNP-0082175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionist