Provider Demographics
NPI:1063968311
Name:MINOR, DENEEN
Entity type:Individual
Prefix:
First Name:DENEEN
Middle Name:
Last Name:MINOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6827 S CHAMPLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-4114
Mailing Address - Country:US
Mailing Address - Phone:312-805-6355
Mailing Address - Fax:
Practice Address - Street 1:6827 S. CHAMPLAIN AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:312-805-6355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILM560-1728-9741172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver