1629736285 NPI number — MS. DIANE MARIE SHALLCROSS APRN, FPA, PMHNP-BC

Table of content: MS. DIANE MARIE SHALLCROSS APRN, FPA, PMHNP-BC (NPI 1629736285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629736285 NPI number — MS. DIANE MARIE SHALLCROSS APRN, FPA, PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHALLCROSS
Provider First Name:
DIANE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, FPA, PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629736285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
218 STATE ST STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CHARLES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60174-1841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-341-0297
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 STATE ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CHARLES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60174-1841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-893-9417
Provider Business Practice Location Address Fax Number:
224-276-7254
Provider Enumeration Date:
12/01/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  277.003222 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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