Healthcare Provider Details

I. General information

NPI: 1588285324
Provider Name (Legal Business Name): STEFANNI ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 W HARRISON ST
CHICAGO IL
60612-3801
US

IV. Provider business mailing address

365 N HALSTED ST APT 1810
CHICAGO IL
60661-1376
US

V. Phone/Fax

Practice location:
  • Phone: 312-947-8800
  • Fax:
Mailing address:
  • Phone: 269-760-1975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number041423934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: