=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316653470
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRYCJA MOZDZIERZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2023
-----------------------------------------------------
Last Update Date | 10/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2160 S 1ST AVE
-----------------------------------------------------
City | MAYWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60153-3328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-327-1313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11900 NIAGRA LN
-----------------------------------------------------
City | HUNTLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60142-8139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-856-7357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209026719
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------