=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366800906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TATIANA VITALIA BUONICORE APRN-FPA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2016
-----------------------------------------------------
Last Update Date | 03/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5635 STATE RD
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60459-2051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-424-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5635 STATE RD
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60459-2051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-424-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 277001003
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 277001003
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------