Provider Demographics
NPI:1386187912
Name:VICENTENO, AZALEA
Entity type:Individual
Prefix:
First Name:AZALEA
Middle Name:
Last Name:VICENTENO
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 1:1464 S MICHIGAN AVE
Mailing Address - Street 2:1402
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3711
Mailing Address - Country:US
Mailing Address - Phone:312-560-8368
Mailing Address - Fax:
Practice Address - Street 1:3600 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2319
Practice Address - Country:US
Practice Address - Phone:773-782-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily