Healthcare Provider Details

I. General information

NPI: 1871039412
Provider Name (Legal Business Name): AL U SANGO FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 WALNUT CREEK LN UNIT 3506
LISLE IL
60532-1946
US

IV. Provider business mailing address

420 WALNUT CREEK LN UNIT 3506
LISLE IL
60532-1946
US

V. Phone/Fax

Practice location:
  • Phone: 708-364-0580
  • Fax:
Mailing address:
  • Phone: 708-364-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.014490
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: