Healthcare Provider Details

I. General information

NPI: 1649637976
Provider Name (Legal Business Name): LIBIN MANUEL ZEVALLOS FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LIBIN MANUEL ZEVALLOS QUINONEZ

II. Dates (important events)

Enumeration Date: 01/17/2016
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4952 W IRVING PARK RD SUITE 300
CHICAGO IL
60641-2640
US

IV. Provider business mailing address

4952 W IRVING PARK RD SUITE 300
CHICAGO IL
60641-2640
US

V. Phone/Fax

Practice location:
  • Phone: 773-942-6141
  • Fax: 847-672-4799
Mailing address:
  • Phone: 773-942-6141
  • Fax: 847-672-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.473317
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238.000480
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.022777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: