Healthcare Provider Details

I. General information

NPI: 1336317809
Provider Name (Legal Business Name): MS. YVONNE MISKIEWICZ SHORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 BURLINGTON AVE
WESTERN SPRINGS IL
60558-1516
US

IV. Provider business mailing address

1023 BURLINGTON AVE
WESTERN SPRINGS IL
60558-1516
US

V. Phone/Fax

Practice location:
  • Phone: 708-354-0826
  • Fax: 708-354-0867
Mailing address:
  • Phone: 708-354-0826
  • Fax: 708-354-0867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: