Healthcare Provider Details

I. General information

NPI: 1518465632
Provider Name (Legal Business Name): ELIZABETH BOLANOS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4327 S ARCHER AVE
CHICAGO IL
60632-2844
US

IV. Provider business mailing address

PO BOX 746721
ATLANTA GA
30374-6721
US

V. Phone/Fax

Practice location:
  • Phone: 773-242-2370
  • Fax:
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209016790
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: