Healthcare Provider Details

I. General information

NPI: 1528507548
Provider Name (Legal Business Name): ELIZABETH HULTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4711 GOLF RD
SKOKIE IL
60076-1224
US

IV. Provider business mailing address

4711 GOLF RD
SKOKIE IL
60076-1224
US

V. Phone/Fax

Practice location:
  • Phone: 847-235-6033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberW114232
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: