Healthcare Provider Details

I. General information

NPI: 1770045049
Provider Name (Legal Business Name): ALISSA MARIE WINNER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST STE 400
CHICAGO IL
60612-4861
US

IV. Provider business mailing address

1611 W HARRISON ST STE 400
CHICAGO IL
60612-4861
US

V. Phone/Fax

Practice location:
  • Phone: 877-632-6637
  • Fax: 708-409-5179
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71010167A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209019124
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041404716
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: