Healthcare Provider Details

I. General information

NPI: 1104780113
Provider Name (Legal Business Name): AZHANAE KIRKWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2025
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 W 118TH ST
CHICAGO IL
60628-5329
US

IV. Provider business mailing address

524 W 118TH ST
CHICAGO IL
60628-5329
US

V. Phone/Fax

Practice location:
  • Phone: 708-571-6180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: