Healthcare Provider Details

I. General information

NPI: 1457752743
Provider Name (Legal Business Name): ANNIE MOY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3637 N SOUTHPORT AVE
CHICAGO IL
60613-3709
US

IV. Provider business mailing address

3637 N SOUTHPORT AVE
CHICAGO IL
60613-3709
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209011482
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: