Healthcare Provider Details

I. General information

NPI: 1598163560
Provider Name (Legal Business Name): ANGELA BOOMSMA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 W 95TH ST STE 400
EVERGREEN PARK IL
60805-2755
US

IV. Provider business mailing address

5106 MUSEUM DR
OAK LAWN IL
60453-7005
US

V. Phone/Fax

Practice location:
  • Phone: 708-424-7600
  • Fax: 708-424-7605
Mailing address:
  • Phone: 708-424-7600
  • Fax: 708-424-7606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-012206
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-012206
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209012206
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number041370468
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: