Healthcare Provider Details

I. General information

NPI: 1679721633
Provider Name (Legal Business Name): CYNTHIA L. BOOTH RN, MS, PCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST # 2E CHILDREN AND ADOLESCENT CENTER
CHICAGO IL
60612-4319
US

IV. Provider business mailing address

1919 W TAYLOR ST RM 808 CHILDREN'S HABILITATION CLINIC
CHICAGO IL
60612-7246
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7202
  • Fax: 312-413-3445
Mailing address:
  • Phone: 312-996-1376
  • Fax: 312-413-3445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number041-227271
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number209-007230
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: