Healthcare Provider Details

I. General information

NPI: 1205603834
Provider Name (Legal Business Name): ANISSA VACHACHIRA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 S MARYLAND AVE
CHICAGO IL
60637-1426
US

IV. Provider business mailing address

5700 S MARYLAND AVE
CHICAGO IL
60637-1426
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025523
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: