Healthcare Provider Details

I. General information

NPI: 1205393014
Provider Name (Legal Business Name): RUTHIE CELESTINE GAVIN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12251 S 80TH AVE
PALOS HEIGHTS IL
60463
US

IV. Provider business mailing address

12251 S 80TH AVE STE 1630
PALOS HEIGHTS IL
60463-1256
US

V. Phone/Fax

Practice location:
  • Phone: 630-257-1111
  • Fax: 630-257-1115
Mailing address:
  • Phone: 708-923-5173
  • Fax: 708-923-5018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.019276
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number041.322139
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: