Healthcare Provider Details

I. General information

NPI: 1659120111
Provider Name (Legal Business Name): MALGORZATA HELENA CUDZICH NOWAKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2024
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 W LAKE ST UNIT 1
MELROSE PARK IL
60160-4042
US

IV. Provider business mailing address

1350 W LAKE ST UNIT 1
MELROSE PARK IL
60160-4042
US

V. Phone/Fax

Practice location:
  • Phone: 708-343-8512
  • Fax: 708-343-8529
Mailing address:
  • Phone: 630-229-5444
  • Fax: 708-615-7547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209029723
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209029723
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: