MEDICARE: URSLA U NWAWUEZE NURSE PRACTITIONER

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209022911	IL

General Provider Information

NPI Number	:	1588243976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	URSLA U NWAWUEZE NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	59 DEERPATH RD
Second Line	:
City	:	MATTESON
State	:	IL
Zip	:	60443-1125
Country	:	US
Telephone Number	:	708-262-8344
Fax Number	:

Provider Business Practice Location Address
First Line	:	8201 S ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-4626
Country	:	US
Telephone Number	:	708-262-8344
Fax Number	:

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

Provider Enumeration Date	:	04/05/2021
Last Update Date	:	06/09/2021

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