Healthcare Provider Details

I. General information

NPI: 1235374315
Provider Name (Legal Business Name): MARIA A TEJADA CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 12/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 S ARCHER AVE
CHICAGO IL
60608-6837
US

IV. Provider business mailing address

3450 S ARCHER AVE
CHICAGO IL
60608-6837
US

V. Phone/Fax

Practice location:
  • Phone: 773-972-7462
  • Fax:
Mailing address:
  • Phone: 773-972-7462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209007360
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: