Healthcare Provider Details

I. General information

NPI: 1609332188
Provider Name (Legal Business Name): MARIA TARALA APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA VERONICA JIMENEZ

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 09/29/2026
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12251 S 80TH AVE
PALOS HEIGHTS IL
60463-1256
US

IV. Provider business mailing address

12251 S 80TH AVE
PALOS HEIGHTS IL
60463-1290
US

V. Phone/Fax

Practice location:
  • Phone: 630-257-1111
  • Fax: 630-257-1115
Mailing address:
  • Phone: 708-923-5869
  • Fax: 708-923-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018455
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.018455
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: