MEDICARE: JELENA FISHMAN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	041361670	IL

General Provider Information

NPI Number	:	1194156307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JELENA FISHMAN FNP

Provider Business Mailing Address
First Line	:	49W161 HINCKLEY RD
Second Line	:
City	:	BIG ROCK
State	:	IL
Zip	:	60511-9314
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	49W161 HINCKLEY RD
Second Line	:
City	:	BIG ROCK
State	:	IL
Zip	:	60511-9314
Country	:	US
Telephone Number	:	773-330-6535
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2013
Last Update Date	:	12/13/2013

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