=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053022152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESSENTIAL HEALTHNP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2022
-----------------------------------------------------
Last Update Date | 04/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2315 E 93RD ST STE 339
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-3916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-590-1975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8833 S CRANDON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-3051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-590-1975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICOLE Q WILSON
-----------------------------------------------------
Credential | APN
-----------------------------------------------------
Telephone | 312-590-1975
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------