=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962945261
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BASIRAT ROMOKE BALE APN, DNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2016
-----------------------------------------------------
Last Update Date | 07/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5841 S MARYLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-834-4946
-----------------------------------------------------
Fax | 773-834-2058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9745 S KARLOV AVE APT. 203
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-3389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-299-3064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 209014251
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------