Healthcare Provider Details

I. General information

NPI: 1285172643
Provider Name (Legal Business Name): CAILIAN MO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

3834 S HERMITAGE AVE
CHICAGO IL
60609-2006
US

V. Phone/Fax

Practice location:
  • Phone: 773-470-3735
  • Fax:
Mailing address:
  • Phone: 773-470-3735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number041411039
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209015537
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: