Healthcare Provider Details

I. General information

NPI: 1215685565
Provider Name (Legal Business Name): TAKALA B FOMOND LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9150 CRAWFORD AVE # L1
SKOKIE IL
60076-1700
US

IV. Provider business mailing address

2916 CENTRAL ST # 2A
EVANSTON IL
60201-1212
US

V. Phone/Fax

Practice location:
  • Phone: 224-420-6894
  • Fax:
Mailing address:
  • Phone: 224-420-6894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.595283
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: