=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366076630
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBRA CHUDZIK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2020
-----------------------------------------------------
Last Update Date | 02/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5841 S MARYLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-307-9837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14620 WESTWOOD DR
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60462-1970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-307-9837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 209018977
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------