Healthcare Provider Details

I. General information

NPI: 1437665411
Provider Name (Legal Business Name): ALOHA PENAFLOR LEBLANC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 N CALIFORNIA AVE STE F101
CHICAGO IL
60625-0035
US

IV. Provider business mailing address

2579 W MONTROSE AVE APT 3S
CHICAGO IL
60618-1518
US

V. Phone/Fax

Practice location:
  • Phone: 773-561-5809
  • Fax:
Mailing address:
  • Phone: 312-371-2816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209016903
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209016903
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: