Basic Information
| Provider Information | |||||||||
| NPI: | 1255860870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLLYSON | ||||||||
| FirstName: | MIA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5215 N CALIFORNIA AVE # 101 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606257014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735615809 | ||||||||
| FaxNumber: | 7735615946 | ||||||||
| Practice Location | |||||||||
| Address1: | 5215 N CALIFORNIA AVE # 101 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606257014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735615809 | ||||||||
| FaxNumber: | 7735615946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 06/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 041-236508 | IL | Y | Nursing Service Providers | Registered Nurse | General Practice |
No ID Information.