Healthcare Provider Details

I. General information

NPI: 1750202784
Provider Name (Legal Business Name): ANIYAH ROYANA RENEE CLEMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 W 111TH ST
OAK LAWN IL
60453-5574
US

IV. Provider business mailing address

996 ROYAL MARCO WAY
MARCO ISLAND FL
34145-1829
US

V. Phone/Fax

Practice location:
  • Phone: 708-634-0821
  • Fax:
Mailing address:
  • Phone: 469-694-1754
  • Fax: 818-758-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: