MEDICARE: UTA J TICHAWA RN, APN-BC, ANP

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	363LA2200X	Adult Health Nurse Practitioner	209.007356	IL

General Provider Information

NPI Number	:	1821233446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	UTA J TICHAWA RN, APN-BC, ANP

Provider Business Mailing Address
First Line	:	1426 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5698
Country	:	US
Telephone Number	:	773-925-4700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1426 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5698
Country	:	US
Telephone Number	:	773-925-4700
Fax Number	:

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

Provider Enumeration Date	:	12/10/2008
Last Update Date	:	12/10/2008

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