Provider Demographics
NPI:1114748928
Name:MOOSE, SHANNON LYNN (ATC, ROT, LAT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:MOOSE
Suffix:
Gender:F
Credentials:ATC, ROT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 CHIPPEWA DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1387
Mailing Address - Country:US
Mailing Address - Phone:224-805-1199
Mailing Address - Fax:
Practice Address - Street 1:255 RED GATE RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-6396
Practice Address - Country:US
Practice Address - Phone:224-805-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960041842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer