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General NPI Number Information
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NPI Number | 1174335004
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Entity Type | Individual
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Provider Name | WANDA NICOLE TATUM
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Gender | Female
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Dates
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Enumeration Date | 01/27/2025
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Last Update Date | 01/27/2025
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Provider Practice Location Address
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Address Line | 95 W MEADOW DR
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City | CORTLAND
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State | IL
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Zip | 60112-4230
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Country | US
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Telephone | 312-307-1651
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Fax |
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Provider Business Mailing Address
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Address Line | 95 W MEADOW DR
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City | CORTLAND
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State | IL
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Zip | 60112-4230
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Country | US
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Telephone | 312-307-1651
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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 | 172A00000X
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Taxonomy Name | Driver
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License Number | T35091465782
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License Number State | IL
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