Healthcare Provider Details

I. General information

NPI: 1225675267
Provider Name (Legal Business Name): AGNES CALLAO VIRATA-DELGADO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 NORTH SAWYER AVE
CHICAGO IL
60618-1211
US

IV. Provider business mailing address

4321 NORTH SAWYER AVE
CHICAGO IL
60618-1211
US

V. Phone/Fax

Practice location:
  • Phone: 773-905-3139
  • Fax:
Mailing address:
  • Phone: 773-905-3139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number770976
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number770976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: