Active NPI
Suzan Cathleen Shane-Gray, APN, EDD
- Pediatric Clinical Nurse Specialist
- Peoria, IL
National Provider Identifier
1144525452
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Clinical Nurse Specialist
- License
- 209.008562
- Practice address
- 530 NE Glen Oak Ave
Pob 113
Peoria, IL 61637-0001 - Phone
- (309) 224-8683
- NPI assigned
- Jan 18, 2011
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Clinical Nurse Specialist | 364SP0200X | 209.008562 | IL | Primary |
Addresses
Primary practice location
530 NE Glen Oak Ave
Pob 113
Peoria, IL 61637-0001
Mailing address
530 NE Glen Oak Ave
Pob 113
Peoria, IL 61637-0001
Phone (309) 224-8683
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Certified Nurse Specialist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 209.008562 | IL | MD | Pediatric Clinical Nurse Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1295308800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1295308800000",
"number": "1144525452",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "530 NE GLEN OAK AVE",
"address_2": "POB 113",
"city": "PEORIA",
"state": "IL",
"postal_code": "616370001",
"telephone_number": "309-224-8683"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "530 NE GLEN OAK AVE",
"address_2": "POB 113",
"city": "PEORIA",
"state": "IL",
"postal_code": "616370001",
"telephone_number": "309-224-8683"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SHANE-GRAY",
"first_name": "SUZAN",
"middle_name": "CATHLEEN",
"name_prefix": "Dr.",
"credential": "APN, EDD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2011-01-18",
"last_updated": "2011-01-18",
"status": "A"
},
"taxonomies": [
{
"code": "364SP0200X",
"taxonomy_group": "",
"desc": "Clinical Nurse Specialist, Pediatrics",
"state": "IL",
"license": "209.008562",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Peoria, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 18, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.