Healthcare Provider Details

I. General information

NPI: 1225559727
Provider Name (Legal Business Name): ESTRELLA SEPULVEDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W SUPERIOR ST
CHICAGO IL
60622-5646
US

IV. Provider business mailing address

2009 W CONCORD PL
CHICAGO IL
60647-5526
US

V. Phone/Fax

Practice location:
  • Phone: 312-666-3494
  • Fax:
Mailing address:
  • Phone: 219-588-2655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209015872
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.015872
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: