Healthcare Provider Details

I. General information

NPI: 1700117736
Provider Name (Legal Business Name): DENICIA CLARK ROLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 20TH ST
ZION IL
60099-1655
US

IV. Provider business mailing address

2625 20TH ST
ZION IL
60099-1655
US

V. Phone/Fax

Practice location:
  • Phone: 847-757-7827
  • Fax:
Mailing address:
  • Phone: 847-757-7827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2471B0102X
TaxonomyBone Densitometry Radiologic Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: