Provider Demographics
NPI:1306662606
Name:GRAUE, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GRAUE
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 1:9125 S 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1601
Mailing Address - Country:US
Mailing Address - Phone:859-693-0045
Mailing Address - Fax:
Practice Address - Street 1:9505 142ND ST STE 300
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4294
Practice Address - Country:US
Practice Address - Phone:859-693-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL131.011722374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician