Healthcare Provider Details

I. General information

NPI: 1588304059
Provider Name (Legal Business Name): ANQUINETTE COLVIN REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANQUINETTE COLVIN REGISTERED NURSE

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 07/21/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8543 S ASHLAND AVE
CHICAGO IL
60620-4710
US

IV. Provider business mailing address

16601 LUELLA AVE
SOUTH HOLLAND IL
60473-2618
US

V. Phone/Fax

Practice location:
  • Phone: 708-925-4585
  • Fax: 708-575-2442
Mailing address:
  • Phone: 708-715-4586
  • Fax: 708-575-2442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number041291124
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041291124
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: