Healthcare Provider Details

I. General information

NPI: 1669809869
Provider Name (Legal Business Name): FOTINI MORAGIANNIS WICKMAN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FOTINI MORAGIANNIS AUD

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LAKE ST STE 621
OAK PARK IL
60301-1136
US

IV. Provider business mailing address

1010 LAKE ST STE 621
OAK PARK IL
60301-1136
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-4363
  • Fax: 708-848-7233
Mailing address:
  • Phone: 708-848-4363
  • Fax: 708-848-7233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147001186
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: