Healthcare Provider Details

I. General information

NPI: 1306653555
Provider Name (Legal Business Name): MAYA CRAWFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 W 63RD
CHICAGO IL
60621
US

IV. Provider business mailing address

641 W 63RD ST
CHICAGO IL
60621-2032
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number041.539444
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: