Provider Demographics
NPI:1245117837
Name:HARRIS, ARZETTA
Entity type:Individual
Prefix:
First Name:ARZETTA
Middle Name:
Last Name:HARRIS
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 1:4622 SUNDERMAN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6270
Mailing Address - Country:US
Mailing Address - Phone:779-772-9309
Mailing Address - Fax:
Practice Address - Street 1:4622 SUNDERMAN RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6270
Practice Address - Country:US
Practice Address - Phone:779-772-9309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.131948164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse