Healthcare Provider Details

I. General information

NPI: 1053093781
Provider Name (Legal Business Name): JUANATA MUA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9119 S EXCHANGE AVE
CHICAGO IL
60617-4225
US

IV. Provider business mailing address

9119 S EXCHANGE AVE
CHICAGO IL
60617-4225
US

V. Phone/Fax

Practice location:
  • Phone: 773-768-5000
  • Fax:
Mailing address:
  • Phone: 773-449-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.027546
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: