Healthcare Provider Details

I. General information

NPI: 1245931021
Provider Name (Legal Business Name): RUTHIE CONSUELA NTANDJA PHLEBOTOMIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RUTHIE CONSUELA HARRIS

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 03/17/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 E. 87TH ST SUITE 104
CHICAGO IL
60617
US

IV. Provider business mailing address

1722 E 84TH ST
CHICAGO IL
60617-2203
US

V. Phone/Fax

Practice location:
  • Phone: 773-577-0246
  • Fax:
Mailing address:
  • Phone: 312-388-1235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number20-0997Y13
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: