Healthcare Provider Details

I. General information

NPI: 1730156779
Provider Name (Legal Business Name): ELIZABETH ANN BOHLING NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE MC 118
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

13838 S CROISSANT DR
BURNHAM IL
60633-2101
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-6366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1595-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: