Healthcare Provider Details

I. General information

NPI: 1861490138
Provider Name (Legal Business Name): MARIAELENA J. FAGADORE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4254 W 55TH ST
CHICAGO IL
60632-4642
US

IV. Provider business mailing address

4254 W 55TH ST
CHICAGO IL
60632-4642
US

V. Phone/Fax

Practice location:
  • Phone: 773-582-5200
  • Fax: 773-582-2772
Mailing address:
  • Phone: 773-582-5200
  • Fax: 773-582-2772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberR45506
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number9244538
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209-015320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: