Healthcare Provider Details

I. General information

NPI: 1912303280
Provider Name (Legal Business Name): MICHELLE O'CONNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201
US

IV. Provider business mailing address

1916 DES PLAINES AVE
PARK RIDGE IL
60068-3710
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209012180
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: