Healthcare Provider Details

I. General information

NPI: 1538957469
Provider Name (Legal Business Name): TANYARAT SUWANNETR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

4730 N TROY ST
CHICAGO IL
60625-4423
US

V. Phone/Fax

Practice location:
  • Phone: 312-947-8800
  • Fax:
Mailing address:
  • Phone: 773-576-4231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number209.033384
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: