Healthcare Provider Details

I. General information

NPI: 1811362197
Provider Name (Legal Business Name): ANNA-MICHELLE VISAK N.P.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 W EXECUTIVE DR
ADDISON IL
60101-5625
US

IV. Provider business mailing address

447 N TRUE ST
GRIFFITH IN
46319-2677
US

V. Phone/Fax

Practice location:
  • Phone: 630-317-3300
  • Fax:
Mailing address:
  • Phone: 219-381-0695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013448
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28214854A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: