Healthcare Provider Details

I. General information

NPI: 1528562931
Provider Name (Legal Business Name): IRINA ISMAILOVA APRN, AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CENTRAL ST STE 730
EVANSTON IL
60201-1779
US

IV. Provider business mailing address

1000 CENTRAL ST STE 730
EVANSTON IL
60201-1779
US

V. Phone/Fax

Practice location:
  • Phone: 847-663-8410
  • Fax:
Mailing address:
  • Phone: 847-663-8410
  • Fax: 847-676-1727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209016811
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209016811
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041375102
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: