MEDICARE: MRS. VIRGINIA BAHENA FNP-BC, PMHNP-BC

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	209025213	IL
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2023019943	IL

General Provider Information

NPI Number	:	1992411987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VIRGINIA BAHENA FNP-BC, PMHNP-BC

Provider Business Mailing Address
First Line	:	5747 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-2353
Country	:	US
Telephone Number	:	773-413-7264
Fax Number	:	773-413-7013

Provider Business Practice Location Address
First Line	:	5747 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-2353
Country	:	US
Telephone Number	:	773-413-7264
Fax Number	:	773-413-7013

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

Provider Enumeration Date	:	01/24/2023
Last Update Date	:	05/08/2024

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