Provider Demographics
NPI:1194387399
Name:MACLIN, TWANIQUA (FNP)
Entity Type:Individual
Prefix:
First Name:TWANIQUA
Middle Name:
Last Name:MACLIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 W TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7232
Mailing Address - Country:US
Mailing Address - Phone:312-966-7420
Mailing Address - Fax:312-413-8485
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:312-996-7420
Practice Address - Fax:312-413-8485
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1194387399Medicaid