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General NPI Number Information
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NPI Number | 1063109296
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Entity Type | Individual
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Provider Name | LARONE NUTALL
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Gender | Male
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Dates
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Enumeration Date | 04/19/2023
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Last Update Date | 04/19/2023
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Provider Practice Location Address
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Address Line | 7138 S COLES AVE APT 2A
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City | CHICAGO
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State | IL
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Zip | 60649-2628
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Country | US
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Telephone | 708-915-0517
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 490563
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City | CHICAGO
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State | IL
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Zip | 60649-0035
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Country | US
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Telephone | 708-915-0517
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | 095808
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License Number State | IL
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