MEDICARE: MISS PATRYCJA ANNA PTAK BSN, RNC-NIC, IBCLC

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	163WL0100X	Lactation Consultant (Registered Nurse)	L-56770	IL
2	163WN0002X	Neonatal Intensive Care Registered Nurse	041345461	IL

General Provider Information

NPI Number	:	1710739370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS PATRYCJA ANNA PTAK BSN, RNC-NIC, IBCLC

Provider Business Mailing Address
First Line	:	5803 N CAMPBELL AVE APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-5445
Country	:	US
Telephone Number	:	773-220-4973
Fax Number	:

Provider Business Practice Location Address
First Line	:	5803 N CAMPBELL AVE APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-5445
Country	:	US
Telephone Number	:	773-220-4973
Fax Number	:

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

Provider Enumeration Date	:	04/04/2024
Last Update Date	:	04/04/2024

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