MEDICARE: JANUARY AYSON IMBUIDO NURSE PRACTITIONER

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	363LG0600X	Gerontology Nurse Practitioner	209.030460	IL
2	363LA2200X	Adult Health Nurse Practitioner	209.030460	IL

General Provider Information

NPI Number	:	1447077219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANUARY AYSON IMBUIDO NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	1264 EVERGREEN AVE
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60016-4321
Country	:	US
Telephone Number	:	224-848-2195
Fax Number	:

Provider Business Practice Location Address
First Line	:	2405 BIG WOODS DR
Second Line	:
City	:	BATAVIA
State	:	IL
Zip	:	60510-7650
Country	:	US
Telephone Number	:	630-277-9651
Fax Number	:	847-972-6265

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

Provider Enumeration Date	:	09/24/2024
Last Update Date	:	06/05/2025

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