MEDICARE: MRS. TANYA MARIA RICHARDSON-BELGRAVE CNP

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	363LF0000X	Family Nurse Practitioner	209009520	IL

General Provider Information

NPI Number	:	1912260407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TANYA MARIA RICHARDSON-BELGRAVE CNP

Provider Business Mailing Address
First Line	:	350 N WALL ST
Second Line	:
City	:	KANKAKEE
State	:	IL
Zip	:	60901-2901
Country	:	US
Telephone Number	:	815-936-7371
Fax Number	:	815-936-6971

Provider Business Practice Location Address
First Line	:	1701 E COURT ST
Second Line	:
City	:	KANKAKEE
State	:	IL
Zip	:	60901-2670
Country	:	US
Telephone Number	:	815-935-9394
Fax Number	:

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

Provider Enumeration Date	:	06/19/2012
Last Update Date	:	06/19/2012

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