Provider Demographics
NPI:1033777552
Name:OWENS, IYSHA A
Entity Type:Individual
Prefix:
First Name:IYSHA
Middle Name:A
Last Name:OWENS
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 1:6546 S CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-1309
Mailing Address - Country:US
Mailing Address - Phone:773-219-9612
Mailing Address - Fax:
Practice Address - Street 1:6546 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1309
Practice Address - Country:US
Practice Address - Phone:773-219-9612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)