=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013635465
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALITHIA MARSH-GARRETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2022
-----------------------------------------------------
Last Update Date | 08/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1611 S CICERO AVE
-----------------------------------------------------
City | CICERO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60804-1520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-477-4840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26460 NETWORK PL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-1264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-257-2820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209025615
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------