MEDICARE: DARA ELIZABETH WILSON NP-C

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	209023882	IL

General Provider Information

NPI Number	:	1578233631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARA ELIZABETH WILSON NP-C

Provider Business Mailing Address
First Line	:	1111 W DIVERSEY PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1318
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 W DIVERSEY PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1318
Country	:	US
Telephone Number	:	773-270-5600
Fax Number	:

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

Provider Enumeration Date	:	09/20/2021
Last Update Date	:	09/20/2021

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