Healthcare Provider Details

I. General information

NPI: 1821766221
Provider Name (Legal Business Name): MATT VATANATUNYAKUM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 11/17/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 S ROSELLE RD
SCHAUMBURG IL
60193-2925
US

IV. Provider business mailing address

519 S ROSELLE RD
SCHAUMBURG IL
60193-2925
US

V. Phone/Fax

Practice location:
  • Phone: 847-985-0600
  • Fax: 847-985-3786
Mailing address:
  • Phone: 847-985-0600
  • Fax: 847-985-3786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025739
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: