Healthcare Provider Details

I. General information

NPI: 1417905100
Provider Name (Legal Business Name): AMY B. PAWASARAT APN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CHILDRENS PLAZA BOX #155
CHICAGO IL
60614-3363
US

IV. Provider business mailing address

2300 CHILDRENS PLAZA BOX #155
CHICAGO IL
60614-3363
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-3684
  • Fax: 773-880-3208
Mailing address:
  • Phone: 773-880-3684
  • Fax: 773-880-3208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209001371
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: