Provider Demographics
NPI:1104873140
Name:MIKAITIS-ROSSI, TANIA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:MIKAITIS-ROSSI
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 W TOUHY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-1100
Mailing Address - Country:US
Mailing Address - Phone:224-508-0382
Mailing Address - Fax:888-255-4358
Practice Address - Street 1:6201 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-1100
Practice Address - Country:US
Practice Address - Phone:224-508-0382
Practice Address - Fax:888-255-4358
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005514363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1295941573OtherTYPE 2 NPI
IL1295941573OtherTYPE 2 NPI
K37843Medicare PIN