MEDICARE: TAWANNA HENRY

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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1336767086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAWANNA HENRY

Provider Business Mailing Address
First Line	:	PO BOX 53651
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-0651
Country	:	US
Telephone Number	:	773-251-9097
Fax Number	:

Provider Business Practice Location Address
First Line	:	11001 S MICHIGAN AVE STE 400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-4308
Country	:	US
Telephone Number	:	773-251-9097
Fax Number	:

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

Provider Enumeration Date	:	07/09/2020
Last Update Date	:	06/24/2022

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