Healthcare Provider Details

I. General information

NPI: 1114269784
Provider Name (Legal Business Name): ERICA TAYABAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 N MICHIGAN AVE SUITE 530
CHICAGO IL
60611-2826
US

IV. Provider business mailing address

4303 N PAULINA ST APT 2
CHICAGO IL
60613-2499
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-7970
  • Fax:
Mailing address:
  • Phone: 630-750-8459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209009992
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: