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General NPI Number Information
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NPI Number | 1720774938
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Entity Type | Organization
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Legal Business Name | PRESTIGE AESTHETICS AND HYDRATION LOUNGE
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Dates
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Enumeration Date | 04/12/2023
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Last Update Date | 06/12/2023
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Provider Practice Location Address
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Address Line | 1761 N DILLEYS RD STE 108-9
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City | GURNEE
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State | IL
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Zip | 60031-1711
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Country | US
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Telephone | 720-343-9979
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Fax |
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Provider Business Mailing Address
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Address Line | 1761 N DILLEYS RD STE 108-9
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City | GURNEE
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State | IL
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Zip | 60031-1711
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Country | US
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Telephone | 720-343-9979
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Fax |
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Authorized Official
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Title or Position | FNP
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Name | DIESAWIT T HANSOM
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Credential | FNP
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Telephone | 720-343-9799
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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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