Healthcare Provider Details

I. General information

NPI: 1306117213
Provider Name (Legal Business Name): REGINA WAN MSN, NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2012
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 E 93RD ST
CHICAGO IL
60617-3909
US

IV. Provider business mailing address

2320 E 93RD ST
CHICAGO IL
60617-3909
US

V. Phone/Fax

Practice location:
  • Phone: 773-967-5097
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number209009357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: