Healthcare Provider Details

I. General information

NPI: 1740192137
Provider Name (Legal Business Name): BEVERLY LYNN PONULAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S 5TH AVE
HINES IL
60141-3030
US

IV. Provider business mailing address

15330 S FRANCIS DR
PLAINFIELD IL
60544-9422
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-2707
  • Fax:
Mailing address:
  • Phone: 708-202-2707
  • Fax: 815-953-0888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number041.282903
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: