Provider Demographics
NPI:1992923585
Name:WYATT, SHANNON DIANE (ATC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DIANE
Last Name:WYATT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 W OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4229
Mailing Address - Country:US
Mailing Address - Phone:773-805-2119
Mailing Address - Fax:
Practice Address - Street 1:1145 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1529
Practice Address - Country:US
Practice Address - Phone:708-386-2086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer