Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036145164 | IL |
Y | 207QS0010X | Family Doctor - Sports Medicine | 036145164 | IL |
NPI | 1326429937 |
---|---|
Provider Name | Shannon Marie Powers |
First Address | Skokie, IL 60076-1214 |
Second Address | Skokie, IL 60076 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2015 |
Last Update Date | 10/10/2019 |