Healthcare Provider Details

I. General information

NPI: 1043813165
Provider Name (Legal Business Name): ELISABETH JANETTE MIWA MSN, APRN, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 W NORTH AVE
MELROSE PARK IL
60160-1612
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 888-584-7888
  • Fax:
Mailing address:
  • Phone: 708-216-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.021767
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: