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General NPI Number Information
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NPI Number | 1861490138
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Entity Type | Individual
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Provider Name | MARIAELENA J. FAGADORE CNP
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Gender | Female
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Dates
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Enumeration Date | 07/12/2005
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Last Update Date | 04/11/2017
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Provider Practice Location Address
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Address Line | 4254 W 55TH ST
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City | CHICAGO
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State | IL
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Zip | 60632-4642
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Country | US
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Telephone | 773-582-5200
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Fax | 773-582-2772
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Provider Business Mailing Address
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Address Line | 4254 W 55TH ST
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City | CHICAGO
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State | IL
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Zip | 60632-4642
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Country | US
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Telephone | 773-582-5200
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Fax | 773-582-2772
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0200X
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Taxonomy Name | Pediatric Registered Nurse
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License Number | R45506
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 9244538
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 209-015320
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License Number State | IL
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