Healthcare Provider Details

I. General information

NPI: 1023479417
Provider Name (Legal Business Name): MICIAH PATTON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2016
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4839 W 47TH ST
CHICAGO IL
60638-2039
US

IV. Provider business mailing address

4839 W 47TH ST
CHICAGO IL
60638-2039
US

V. Phone/Fax

Practice location:
  • Phone: 773-735-2345
  • Fax: 773-735-4025
Mailing address:
  • Phone: 773-735-2345
  • Fax: 773-735-4025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013960
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041378934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: