Healthcare Provider Details

I. General information

NPI: 1225806094
Provider Name (Legal Business Name): SHAMEL COLVARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 01/10/2026
Certification Date: 01/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4847 W WASHINGTON BLVD
CHICAGO IL
60644-3628
US

IV. Provider business mailing address

4847 W WASHINGTON BLVD
CHICAGO IL
60644-3628
US

V. Phone/Fax

Practice location:
  • Phone: 312-504-0144
  • Fax:
Mailing address:
  • Phone: 312-504-0144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209029279
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041450134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: