Healthcare Provider Details

I. General information

NPI: 1972144715
Provider Name (Legal Business Name): REBECCA MIRELES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER CROSS BLVD
NEW LENOX IL
60451-9509
US

IV. Provider business mailing address

1900 SILVER CROSS BLVD
NEW LENOX IL
60451-9509
US

V. Phone/Fax

Practice location:
  • Phone: 815-300-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.019873
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: