Healthcare Provider Details

I. General information

NPI: 1548097769
Provider Name (Legal Business Name): IVONA BOUSHEH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 PHEASANT CREEK DR APT 104
NORTHBROOK IL
60062-3369
US

IV. Provider business mailing address

3050 PHEASANT CREEK DR APT 104
NORTHBROOK IL
60062-3369
US

V. Phone/Fax

Practice location:
  • Phone: 773-954-4577
  • Fax:
Mailing address:
  • Phone: 773-954-4577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.030739
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: