Healthcare Provider Details

I. General information

NPI: 1780272294
Provider Name (Legal Business Name): TAWAKALIT F ALAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2021
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 NELSON RD
NEW LENOX IL
60451-8537
US

IV. Provider business mailing address

2050 NELSON RD
NEW LENOX IL
60451-8537
US

V. Phone/Fax

Practice location:
  • Phone: 815-463-5280
  • Fax:
Mailing address:
  • Phone: 815-463-5280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1780272294
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209022622
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041329567
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: