Healthcare Provider Details

I. General information

NPI: 1750757159
Provider Name (Legal Business Name): GUAMEDA EADY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19310 S HALSTED JENCARE NEIGHBORHOOD MEDICAL CENTER GLENWOOD, LLC
GLENWOOD IL
60425
US

IV. Provider business mailing address

19310 S HALSTED JENCARE NEIGHBORHOOD MEDICAL CENTER GLENWOOD, LLC
GLENWOOD IL
60425
US

V. Phone/Fax

Practice location:
  • Phone: 708-300-3132
  • Fax: 708-300-3149
Mailing address:
  • Phone: 708-300-3132
  • Fax: 708-300-3149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209012721
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: