Healthcare Provider Details

I. General information

NPI: 1003405390
Provider Name (Legal Business Name): MEHRUNNISSA TAJ APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1343 MONTCLAIRE CIR
SCHAUMBURG IL
60173-6180
US

IV. Provider business mailing address

1343 MONTCLAIRE CIR
SCHAUMBURG IL
60173-6180
US

V. Phone/Fax

Practice location:
  • Phone: 847-971-8877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209014361
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041247760
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: