Healthcare Provider Details

I. General information

NPI: 1619675774
Provider Name (Legal Business Name): MEAGHAN MCMAHON AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E SUPERIOR ST FL 16
CHICAGO IL
60611-2914
US

IV. Provider business mailing address

250 E SUPERIOR ST FL 16
CHICAGO IL
60611-2914
US

V. Phone/Fax

Practice location:
  • Phone: 312-472-3665
  • Fax: 312-472-4223
Mailing address:
  • Phone: 312-472-3665
  • Fax: 312-472-4223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.454599
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209027189
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: