Healthcare Provider Details

I. General information

NPI: 1689293987
Provider Name (Legal Business Name): RICKEDA ROBINSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RICKEDA GRANBERRY NP

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 S WESTERN AVE STE 201
CHICAGO IL
60643-3225
US

IV. Provider business mailing address

210 S DESPLAINES ST
CHICAGO IL
60661-5500
US

V. Phone/Fax

Practice location:
  • Phone: 773-770-4824
  • Fax:
Mailing address:
  • Phone: 312-654-2720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209020117
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: