Healthcare Provider Details

I. General information

NPI: 1710725767
Provider Name (Legal Business Name): JENNIFER GORMAN BUSWELL FNP-BC, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 05/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 75TH ST
WILLOWBROOK IL
60527-2325
US

IV. Provider business mailing address

9301 BIRCH AVE
MOKENA IL
60448-8324
US

V. Phone/Fax

Practice location:
  • Phone: 630-581-5372
  • Fax: 630-568-3247
Mailing address:
  • Phone: 708-921-5430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209029984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: