Basic Information
| Provider Information | |||||||||
| NPI: | 1376789313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAJDA | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 LAKE COOK RD STE M | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600155234 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601601612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086813200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2008 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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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 | 367500000X | 209007429 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 041334424 | IL | N | Nursing Service Providers | Registered Nurse |
No ID Information.