=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528643228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANISHA ANTONIO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2021
-----------------------------------------------------
Last Update Date | 03/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 WAUKEGAN RD UNIT 371
-----------------------------------------------------
City | GLENVIEW
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60025-5186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-562-2182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 WAUKEGAN RD UNIT 371
-----------------------------------------------------
City | GLENVIEW
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60025-5186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-562-2182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 209022995
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------