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General NPI Number Information
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NPI Number | 1215685565
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Entity Type | Individual
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Provider Name | TAKALA B FOMOND LPN
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Gender | Female
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Dates
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Enumeration Date | 03/15/2022
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Last Update Date | 12/09/2025
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Provider Practice Location Address
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Address Line | 9150 CRAWFORD AVE # L1
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City | SKOKIE
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State | IL
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Zip | 60076-1700
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Country | US
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Telephone | 224-420-6894
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Fax |
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Provider Business Mailing Address
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Address Line | 2916 CENTRAL ST # 2A
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City | EVANSTON
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State | IL
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Zip | 60201-1212
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Country | US
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Telephone | 224-420-6894
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 041.595283
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License Number State | IL
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