Healthcare Provider Details

I. General information

NPI: 1295397446
Provider Name (Legal Business Name): JOAN ANNETTE OLLIE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOAN OLLIE NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 E 87TH ST
CHICAGO IL
60617-3011
US

IV. Provider business mailing address

4233 W 76TH ST APT 201
CHICAGO IL
60652-1244
US

V. Phone/Fax

Practice location:
  • Phone: 773-768-5000
  • Fax: 773-978-8367
Mailing address:
  • Phone: 773-677-4092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017595
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041260739
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: