=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699158949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KINZY KANISHA FRIZZLE O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2015
-----------------------------------------------------
Last Update Date | 04/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 S HARLEM AVE
-----------------------------------------------------
City | STICKNEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-4250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-788-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 S HARLEM AVE
-----------------------------------------------------
City | STICKNEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-4250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-788-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046.010892
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------