MEDICARE: BRETT NICOLE STALLONE

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1336441096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRETT NICOLE STALLONE

Provider Business Mailing Address
First Line	:	353 N DESPLAINES ST
Second Line	:	APT 3704
City	:	CHICAGO
State	:	IL
Zip	:	60661-1234
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	353 N DESPLAINES ST
Second Line	:	APT 3704
City	:	CHICAGO
State	:	IL
Zip	:	60661-1234
Country	:	US
Telephone Number	:	217-416-0401
Fax Number	:

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

Provider Enumeration Date	:	11/30/2010
Last Update Date	:	11/30/2010

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Directions to “ BRETT NICOLE STALLONE ” Practice Location

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