Basic Information
| Provider Information | |||||||||
| NPI: | 1770893158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIELECKI | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S 80TH AVE | ||||||||
| Address2: | MED STAFF OFFICE SUITE 1630 | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089235173 | ||||||||
| FaxNumber: | 7089235018 | ||||||||
| Practice Location | |||||||||
| Address1: | 12251 S 80TH AVE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302571111 | ||||||||
| FaxNumber: | 6302571115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2010 | ||||||||
| LastUpdateDate: | 02/05/2018 | ||||||||
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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 | 363LA2200X | 041246820 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 209.008359 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | F400285932 | 01 | IL | MEDICARE PTAN | OTHER |