Provider Demographics
NPI:1770888901
Name:BARTOLUCCI, SHANNON LYN (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYN
Last Name:BARTOLUCCI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LYN
Other - Last Name:CHEJFEC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:415 ANTHONY ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4419
Mailing Address - Country:US
Mailing Address - Phone:630-864-7410
Mailing Address - Fax:
Practice Address - Street 1:1909 OGDEN AVE STE A
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2602
Practice Address - Country:US
Practice Address - Phone:630-832-1775
Practice Address - Fax:630-832-1775
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.004191363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner