Healthcare Provider Details

I. General information

NPI: 1336623917
Provider Name (Legal Business Name): FAYE GANDEZA IBANEZ CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 N CALIFORNIA AVE STE G115
CHICAGO IL
60625-4971
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-3803
  • Fax: 773-989-3979
Mailing address:
  • Phone: 773-989-3803
  • Fax: 773-878-5726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.018210
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018210
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: