Provider Demographics
NPI:1235302167
Name:WALCZAK, DEBRA ANN (CCNS)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:ANN
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:CCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5547 S MCVICKER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2637
Mailing Address - Country:US
Mailing Address - Phone:773-284-1403
Mailing Address - Fax:
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:312-996-6021
Practice Address - Fax:312-996-9723
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006927364S00000X, 364ST0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364ST0500XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistTransplantation
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist