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General NPI Number Information
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NPI Number | 1487372546
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Entity Type | Organization
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Legal Business Name | PROVIDER STAT PLLC
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Dates
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Enumeration Date | 08/16/2022
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Last Update Date | 01/16/2023
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Provider Practice Location Address
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Address Line | 6374 N LINCOLN AVE STE 312
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City | CHICAGO
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State | IL
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Zip | 60659-1224
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Country | US
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Telephone | 312-308-0219
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Fax |
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Provider Business Mailing Address
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Address Line | 6374 N LINCOLN AVE STE 312
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City | CHICAGO
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State | IL
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Zip | 60659-1224
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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 | OWNER
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Name | DINA ZIMMERMAN
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Credential | FNP
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Telephone | 312-308-0219
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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