=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699857243
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROWEINE Q. STASZCUK N.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2006
-----------------------------------------------------
Last Update Date | 11/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 S KEDZIE AVE ROOM 206
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-2706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-746-6833
-----------------------------------------------------
Fax | 312-746-9049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 S KEDZIE AVE RM 206
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-2706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-775-1589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 209003325
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------