=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558937508
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELAINA MAY BARRAZA DNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2021
-----------------------------------------------------
Last Update Date | 08/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1203 W AUGUSTA BLVD UNIT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-4327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-248-2255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1936 S AUSTIN BLVD
-----------------------------------------------------
City | CICERO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60804-1656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-235-8545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 209023289
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 209023289
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------