1336772920 NPI number — NAHAWAND HASAN KISHTA APRN-FNP

Table of content: NAHAWAND HASAN KISHTA APRN-FNP (NPI 1336772920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336772920 NPI number — NAHAWAND HASAN KISHTA APRN-FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KISHTA
Provider First Name:
NAHAWAND
Provider Middle Name:
HASAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN-FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336772920
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5600 W 87TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURBANK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60459-2902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-952-0000
Provider Business Mailing Address Fax Number:
708-529-7195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5600 W 87TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURBANK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60459-2902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-952-0000
Provider Business Practice Location Address Fax Number:
708-529-7195
Provider Enumeration Date:
02/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  209020626 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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