MEDICARE: ANJALA DELORIS BRANTLEY CNA

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	376K00000X	Nurse's Aide		IL

General Provider Information

NPI Number	:	1295219764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANJALA DELORIS BRANTLEY CNA

Provider Business Mailing Address
First Line	:	10200 GRAND AVE
Second Line	:
City	:	FRANKLIN PARK
State	:	IL
Zip	:	60131-3139
Country	:	US
Telephone Number	:	847-455-5688
Fax Number	:	847-455-0744

Provider Business Practice Location Address
First Line	:	9811 S JEFFERY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-5220
Country	:	US
Telephone Number	:	312-221-6697
Fax Number	:

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

Provider Enumeration Date	:	09/20/2018
Last Update Date	:	09/20/2018

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