Healthcare Provider Details

I. General information

NPI: 1083111777
Provider Name (Legal Business Name): MYRA SIKWATA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9718 S HALSTED ST
CHICAGO IL
60628
US

IV. Provider business mailing address

165 CRESTWOOD DR
MICHIGAN CITY IN
46360-7704
US

V. Phone/Fax

Practice location:
  • Phone: 773-233-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017859
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.017859
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: