Provider Demographics
NPI:1316705239
Name:TAHIYAM, DARYLL HANNAH AMID
Entity type:Individual
Prefix:
First Name:DARYLL HANNAH
Middle Name:AMID
Last Name:TAHIYAM
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 1:1124 CAMELLIA DR APT 3
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3620
Mailing Address - Country:US
Mailing Address - Phone:773-968-3355
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE RM 4602
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:773-702-6222
Practice Address - Fax:773-702-9076
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209029302363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health