Healthcare Provider Details

I. General information

NPI: 1326639493
Provider Name (Legal Business Name): MRS. MELISSA VASTORIA INGRAHAM PICKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10945 S. BUFFALO AVE.
CHICAGO IL
60617
US

IV. Provider business mailing address

10945 S. BUFFALO AVE.
CHICAGO IL
60617
US

V. Phone/Fax

Practice location:
  • Phone: 312-834-1454
  • Fax:
Mailing address:
  • Phone: 312-834-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: