Healthcare Provider Details

I. General information

NPI: 1972414944
Provider Name (Legal Business Name): QUINTELLA CLARICE DENNIS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S PULASKI RD
CHICAGO IL
60624-3653
US

IV. Provider business mailing address

531 S PLYMOUTH CT STE 103
CHICAGO IL
60605-1510
US

V. Phone/Fax

Practice location:
  • Phone: 773-565-4116
  • Fax: 773-565-4117
Mailing address:
  • Phone: 773-565-4116
  • Fax: 773-565-4117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209.033022
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: