Healthcare Provider Details

I. General information

NPI: 1053995332
Provider Name (Legal Business Name): AKI TAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 07/11/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019034168
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: