Healthcare Provider Details

I. General information

NPI: 1366126773
Provider Name (Legal Business Name): TAYLOR ELIZABETH NOGIEC PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 W DIVERSEY PKWY STE 300
CHICAGO IL
60614-8489
US

IV. Provider business mailing address

1660 N LA SALLE DR APT 407
CHICAGO IL
60614-6007
US

V. Phone/Fax

Practice location:
  • Phone: 732-484-1507
  • Fax: 773-248-4291
Mailing address:
  • Phone: 860-389-8386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009837
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: