Healthcare Provider Details

I. General information

NPI: 1578339065
Provider Name (Legal Business Name): GIA CHEZVON SHORT PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8128 S WESTERN AVE REAR UNIT1
CHICAGO IL
60620-5937
US

IV. Provider business mailing address

8128 S WESTERN AVE REAR UNIT1
CHICAGO IL
60620-5937
US

V. Phone/Fax

Practice location:
  • Phone: 312-661-5506
  • Fax: 312-661-5556
Mailing address:
  • Phone: 312-661-5506
  • Fax: 312-661-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number277005820
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: