Healthcare Provider Details

I. General information

NPI: 1750382032
Provider Name (Legal Business Name): CELINE BOERS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 W NORTH AVE
CHICAGO IL
60639-4852
US

IV. Provider business mailing address

1427 FOREST AVE
CALUMET CITY IL
60409-6049
US

V. Phone/Fax

Practice location:
  • Phone: 773-278-6868
  • Fax:
Mailing address:
  • Phone: 773-891-2507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number041183241
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: