=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891537817
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEATA BOGDAN FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2024
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 W 203RD ST
-----------------------------------------------------
City | OLYMPIA FIELDS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60461-1180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-679-1890
-----------------------------------------------------
Fax | 708-747-9859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 713260
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-1260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-469-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209029509
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 209029509
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------