Basic Information
| Provider Information | |||||||||
| NPI: | 1679038186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANDOHAN | ||||||||
| FirstName: | DORIS | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 W MONROE ST STE 1200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606032420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 3046 127TH ST | ||||||||
| Address2: | |||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604061827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083777920 | ||||||||
| FaxNumber: | 7089300414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2019 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71008752A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 209019405 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 71008752A | 01 | IN | NURSE PRACTITIONER LICENSE NUMBER | OTHER |