Healthcare Provider Details

I. General information

NPI: 1336445584
Provider Name (Legal Business Name): MARTHA EGIEBOR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10001 W ROOSEVELT RD STE 308
WESTCHESTER IL
60154-2662
US

IV. Provider business mailing address

865 WILLOW LN
WILLOWBROOK IL
60527-5339
US

V. Phone/Fax

Practice location:
  • Phone: 708-410-2007
  • Fax: 708-410-2017
Mailing address:
  • Phone: 708-410-2007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number1011319
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: