Provider Demographics
NPI:1932409489
Name:DEZYNSKI, CATHERINE SHANNON (WHNP, CNM)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:SHANNON
Last Name:DEZYNSKI
Suffix:
Gender:F
Credentials:WHNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 N CALIFORNIA AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-7014
Mailing Address - Country:US
Mailing Address - Phone:312-666-3494
Mailing Address - Fax:
Practice Address - Street 1:5215 N CALIFORNIA AVE FL 7
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7014
Practice Address - Country:US
Practice Address - Phone:312-666-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008431363LW0102X
IL209-017470367A00000X
IL209071470367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400448067OtherMEDICARE
IL$$$$$$$$$001Medicaid