Healthcare Provider Details

I. General information

NPI: 1225516248
Provider Name (Legal Business Name): STEPHANIE LYNN HALBERG APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 05/16/2020
Certification Date: 05/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N KINGSBURY ST STE RW-6
CHICAGO IL
60610
US

IV. Provider business mailing address

779 W ADAMS ST
CHICAGO IL
60661-3509
US

V. Phone/Fax

Practice location:
  • Phone: 312-222-8230
  • Fax:
Mailing address:
  • Phone: 312-752-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017679
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: