Healthcare Provider Details

I. General information

NPI: 1083173066
Provider Name (Legal Business Name): STEPHANIE SALAMANCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W SUNNYSIDE AVE
CHICAGO IL
60640-5684
US

IV. Provider business mailing address

7501 N OCONTO AVE
CHICAGO IL
60631-4443
US

V. Phone/Fax

Practice location:
  • Phone: 773-935-6126
  • Fax:
Mailing address:
  • Phone: 847-338-4030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018820
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: