Healthcare Provider Details

I. General information

NPI: 1548388846
Provider Name (Legal Business Name): DEBORAH GOLDSTEIN A.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

4135 N PONTIAC AVE
CHICAGO IL
60634-1042
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4150
  • Fax: 312-864-9906
Mailing address:
  • Phone: 773-625-6985
  • Fax: 312-864-9906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number041-239547
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-000191
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: