Healthcare Provider Details

I. General information

NPI: 1487003901
Provider Name (Legal Business Name): MONICA PHELPS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13049 W 29TH ST
BEACH PARK IL
60099-9791
US

IV. Provider business mailing address

13049 W 29TH ST
BEACH PARK IL
60099-9791
US

V. Phone/Fax

Practice location:
  • Phone: 262-515-3385
  • Fax: 224-789-7151
Mailing address:
  • Phone: 262-515-3385
  • Fax: 224-789-7151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number318497
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: