Provider Demographics
NPI:1215126016
Name:MESINA, TEOFILA GONZALES
Entity type:Individual
Prefix:
First Name:TEOFILA
Middle Name:GONZALES
Last Name:MESINA
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 1:6016 W BARRY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-5105
Mailing Address - Country:US
Mailing Address - Phone:773-818-6775
Mailing Address - Fax:
Practice Address - Street 1:6016 W BARRY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-5105
Practice Address - Country:US
Practice Address - Phone:773-818-6775
Practice Address - Fax:773-622-8608
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363799312001Medicaid
IL363799312001Medicaid