Healthcare Provider Details

I. General information

NPI: 1255860870
Provider Name (Legal Business Name): MIA K ROLLYSON RN, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 N CALIFORNIA AVE # 101
CHICAGO IL
60625-7014
US

IV. Provider business mailing address

5215 N CALIFORNIA AVE # 101
CHICAGO IL
60625-7014
US

V. Phone/Fax

Practice location:
  • Phone: 773-561-5809
  • Fax: 773-561-5946
Mailing address:
  • Phone: 773-561-5809
  • Fax: 773-561-5946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041-236508
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: