Provider Demographics
NPI:1508238221
Name:SULTANOVA, JAZIRA (NP)
Entity Type:Individual
Prefix:
First Name:JAZIRA
Middle Name:
Last Name:SULTANOVA
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 1:3922 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-3179
Mailing Address - Country:US
Mailing Address - Phone:815-344-4499
Mailing Address - Fax:815-578-2006
Practice Address - Street 1:3922 MERCY DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-3179
Practice Address - Country:US
Practice Address - Phone:815-344-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.001903363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily