MEDICARE: MICHELLE UBAU FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209.014119	IL

General Provider Information

NPI Number	:	1164976817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE UBAU FNP-BC

Provider Business Mailing Address
First Line	:	600 W FULTON ST STE 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-1262
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1723 HOWARD ST
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-3735
Country	:	US
Telephone Number	:	224-307-8550
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2016
Last Update Date	:	08/11/2016

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