Healthcare Provider Details

I. General information

NPI: 1649760083
Provider Name (Legal Business Name): JOSEPH SPAGNOLA III NP, FPA, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277002403
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209017357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: