Healthcare Provider Details

I. General information

NPI: 1295219764
Provider Name (Legal Business Name): ANJALA DELORIS BRANTLEY CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9811 S JEFFERY AVE
CHICAGO IL
60617-5220
US

IV. Provider business mailing address

10200 GRAND AVE
FRANKLIN PARK IL
60131-3139
US

V. Phone/Fax

Practice location:
  • Phone: 312-221-6697
  • Fax:
Mailing address:
  • Phone: 847-455-5688
  • Fax: 847-455-0744

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: