Healthcare Provider Details

I. General information

NPI: 1669770129
Provider Name (Legal Business Name): ANDREA L BUKIEWICZ CPM, LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 PARK AVE
GRAYSLAKE IL
60030-2341
US

IV. Provider business mailing address

302 PARK AVE
GRAYSLAKE IL
60030-2341
US

V. Phone/Fax

Practice location:
  • Phone: 773-964-6096
  • Fax:
Mailing address:
  • Phone: 773-964-6096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number119-49
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: