Healthcare Provider Details

I. General information

NPI: 1568297752
Provider Name (Legal Business Name): JEZMINE MIZYED FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 N DEARBORN ST STE 300
CHICAGO IL
60610-7377
US

IV. Provider business mailing address

633 W NORTH AVE APT 702
CHICAGO IL
60610-0904
US

V. Phone/Fax

Practice location:
  • Phone: 708-663-0611
  • Fax:
Mailing address:
  • Phone: 708-663-0611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041500433
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: