Healthcare Provider Details

I. General information

NPI: 1225668643
Provider Name (Legal Business Name): JUMANA MANSOUR APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 W RAND RD # 210
ARLINGTON HEIGHTS IL
60004-2315
US

IV. Provider business mailing address

1051 W RAND RD # 210
ARLINGTON HEIGHTS IL
60004-2315
US

V. Phone/Fax

Practice location:
  • Phone: 847-725-8401
  • Fax: 847-454-2236
Mailing address:
  • Phone: 847-725-8401
  • Fax: 847-454-2236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-020431
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: