Basic Information
| Provider Information | |||||||||
| NPI: | 1679941819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TELISZCZAK | ||||||||
| FirstName: | ALLISON | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHACHT | ||||||||
| OtherFirstName: | ALLISON | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10350 HALIGUS RD | ||||||||
| Address2: | |||||||||
| City: | HUNTLEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601429545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8478027112 | ||||||||
| Practice Location | |||||||||
| Address1: | 10350 HALIGUS RD | ||||||||
| Address2: | |||||||||
| City: | HUNTLEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8478027112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2015 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209013024 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209013024 | 01 | IL | STATE LICENSE | OTHER |