Healthcare Provider Details

I. General information

NPI: 1801405733
Provider Name (Legal Business Name): CLAUDIA MEDRANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SUPERIOR ST STE 101
MELROSE PARK IL
60160-4100
US

IV. Provider business mailing address

222 E PEARSON ST APT 2101
CHICAGO IL
60611-7364
US

V. Phone/Fax

Practice location:
  • Phone: 708-406-3040
  • Fax:
Mailing address:
  • Phone: 708-543-8624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041421926
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: