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General NPI Number Information
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NPI Number | 1295488666
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Entity Type | Individual
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Provider Name | DIMETRIUS NUNN
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Gender | Male
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Dates
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Enumeration Date | 01/27/2022
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Last Update Date | 01/27/2022
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Provider Practice Location Address
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Address Line | 11515 S PRAIRIE AVE
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City | CHICAGO
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State | IL
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Zip | 60628-5611
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Country | US
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Telephone | 312-686-4877
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Fax |
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Provider Business Mailing Address
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Address Line | 730 E 157TH PL
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-1525
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Country | US
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Telephone |
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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 | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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License Number State | IL
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