Healthcare Provider Details

I. General information

NPI: 1659932028
Provider Name (Legal Business Name): VIVIANA CARBAJAL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3258 W 111TH ST
CHICAGO IL
60655-2729
US

IV. Provider business mailing address

3258 W 111TH ST
CHICAGO IL
60655-2729
US

V. Phone/Fax

Practice location:
  • Phone: 773-629-8217
  • Fax:
Mailing address:
  • Phone: 773-629-8217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019628
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: