Healthcare Provider Details

I. General information

NPI: 1063728202
Provider Name (Legal Business Name): EMILY N STOUFFER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY N DITTLE NP-C

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST SUITE 400
CHICAGO IL
60612-4861
US

IV. Provider business mailing address

1611 W HARRISON ST SUITE 300
CHICAGO IL
60612-4861
US

V. Phone/Fax

Practice location:
  • Phone: 312-243-4244
  • Fax: 312-942-1517
Mailing address:
  • Phone: 312-243-4244
  • Fax: 312-942-1517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.008183
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: