Healthcare Provider Details

I. General information

NPI: 1275102022
Provider Name (Legal Business Name): TASHICA BRUCE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 W 103RD ST STE 204B
OAK LAWN IL
60453-4868
US

IV. Provider business mailing address

3116 W 100TH ST
EVERGREEN PARK IL
60805-3507
US

V. Phone/Fax

Practice location:
  • Phone: 312-588-9449
  • Fax: 630-381-5279
Mailing address:
  • Phone: 231-638-3389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277.003537
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: