Provider Demographics
NPI:1346786811
Name:MOMAN, TALISHA
Entity Type:Individual
Prefix:
First Name:TALISHA
Middle Name:
Last Name:MOMAN
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 1:7600 S. PULASKI RD.
Mailing Address - Street 2:SUITE 1106
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652
Mailing Address - Country:US
Mailing Address - Phone:773-838-5748
Mailing Address - Fax:
Practice Address - Street 1:7600 S. PULASKI RD.
Practice Address - Street 2:SUITE 1106
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652
Practice Address - Country:US
Practice Address - Phone:773-838-5748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.102708164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse