Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | 209-00538 | IL |
NPI | 1003822552 |
---|---|
Provider Name | Marijo Letizia |
First Address | Elmhurst, IL 60126-4112 |
Second Address | Westmont, IL 60559-1228 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0032243774 | BCBS PROVIDER NUMBER (01) | IL |