MEDICARE: IVO EWANG EWANE REGISTERED NURSE

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	163WH0200X	Home Health Registered Nurse	041745373	IL

General Provider Information

NPI Number	:	1366066219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVO EWANG EWANE REGISTERED NURSE

Provider Business Mailing Address
First Line	:	3116 PRAIRIE ST
Second Line	:
City	:	AURORA
State	:	IL
Zip	:	60506-9229
Country	:	US
Telephone Number	:	630-566-9165
Fax Number	:

Provider Business Practice Location Address
First Line	:	3116 PRAIRIE ST
Second Line	:
City	:	AURORA
State	:	IL
Zip	:	60506-9229
Country	:	US
Telephone Number	:	630-566-9165
Fax Number	:

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

Provider Enumeration Date	:	06/05/2020
Last Update Date	:	06/05/2020

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