Provider Demographics
NPI:1376155275
Name:FATIMA, NAZNEEN
Entity Type:Individual
Prefix:
First Name:NAZNEEN
Middle Name:
Last Name:FATIMA
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 1:4010 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2825
Mailing Address - Country:US
Mailing Address - Phone:773-286-0309
Mailing Address - Fax:
Practice Address - Street 1:4010 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2825
Practice Address - Country:US
Practice Address - Phone:773-286-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.302755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist