=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770216541
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVELISSE SANCHEZ RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2022
-----------------------------------------------------
Last Update Date | 07/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4440 W 95TH ST
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-2600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-389-2542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2011 N 74TH CT
-----------------------------------------------------
City | ELMWOOD PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60707-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-484-8540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Clinical Nurse Specialist
-----------------------------------------------------
License Number | 041331550
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------