Provider Demographics
NPI:1255860870
Name:ROLLYSON, MIA K (RN, MA)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:K
Last Name:ROLLYSON
Suffix:
Gender:F
Credentials:RN, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 N CALIFORNIA AVE # 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-7014
Mailing Address - Country:US
Mailing Address - Phone:773-561-5809
Mailing Address - Fax:773-561-5946
Practice Address - Street 1:5215 N CALIFORNIA AVE # 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7014
Practice Address - Country:US
Practice Address - Phone:773-561-5809
Practice Address - Fax:773-561-5946
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-236508163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice