MEDICARE: MRS. ANQUINETTE COLVIN 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	163W00000X	Registered Nurse	041291124	IL
2	163W00000X	Registered Nurse		IL
3	251E00000X	Home Health Agency
4	251E00000X	Home Health Agency	041291124	IL

General Provider Information

NPI Number	:	1588304059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANQUINETTE COLVIN REGISTERED NURSE

Provider Business Mailing Address
First Line	:	16601 LUELLA AVE
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2618
Country	:	US
Telephone Number	:	708-715-4586
Fax Number	:	708-575-2442

Provider Business Practice Location Address
First Line	:	8543 S ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-4710
Country	:	US
Telephone Number	:	708-925-4585
Fax Number	:	708-575-2442

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

Provider Enumeration Date	:	03/31/2022
Last Update Date	:	07/21/2022

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