Provider Demographics
NPI:1376731638
Name:FUENTES, ROSA L (NP)
Entity Type:Individual
Prefix:MS
First Name:ROSA
Middle Name:L
Last Name:FUENTES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 S MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1447
Mailing Address - Country:US
Mailing Address - Phone:773-702-1000
Mailing Address - Fax:
Practice Address - Street 1:2420 DANBURY DR APT B2
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2096
Practice Address - Country:US
Practice Address - Phone:630-479-3382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006367363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics